How A Hospital Surveyor Conducts The Hospital Survey - Part 2
In the previous post we started discussing the process a nursing home and hospital surveyor goes through to conduct a hospital survey. We got through the first step (task 1).
After Task 1 is completed, the survey team goes to the hospital. This is part of Task 2, The Entrance Activities. During this task the hospital survey team explains the survey process to the hospital and obtains the information they need to conduct the survey. All of the nursing home and hospital surveyors who are on the team should enter the hospital together and present their identification. They announce to the Administrator, or whoever is in charge, that a survey is being conducted. Sometimes the team arrives and the administrator is not available. That is OK, the survey team will not delay the survey.
After the team enters, the team coordinator will conduct what is called an “entrance conference”. This is a short conference that explains the purpose and scope of the survey to the administrator of the hospital and to any staff that are present at the entrance conference. The team coordinator will clarify information with the hospital, discuss expectations for the survey, and get additional information the hospital surveyor team will need. There will also be arrangements made for the team to have a location where they can meet privately during the survey.
In a hospital survey there is no initial tour. This is different than the Nursing Home survey, which we will discuss in other posts.
After the entrance conference, the hospital surveyor team will meet in order to evaluate information gathered, and, if needed, modify any surveyor assignments, as necessary.
A survey requires the review of a certain number of patients and patient records. The hospital survey team will select the patient sample by reviewing the patient list provided by the hospital and selecting patients who represent a cross-section of the patient population and the services provided. The sample size at mid to large hospitals is at least 10 percent of the average daily census, but not fewer than 30 inpatient records. For small general hospitals with an average daily census of 20 patients or less, the sample selected by the survey team will not be fewer than 20 inpatient records. Within the sample, the hospital survey team will select at least one patient from each nursing unit (e.g., med/surg, ICU, OB, pediatrics, specialty units, etc). In addition to the inpatient sample, the nursing home and hospital surveyors will select a sample of outpatients in order to determine if the facility is in compliance with regulations in all their outpatient departments, services, and locations. The sample size may be expanded as needed to assess the hospital’s compliance with the CoP.
In order to protect the confidentiality of the patients selected, the survey team ensures each patient in the sample is given a unique identifier. Patient names and other personally identifiable information is not used when the team writes up the problems found in the survey.
We will continue this discussion in the next post.
Be Safe!
JL
Filed Under Hospitals, Regulations, Survey Task |
Tagged With Hospitals, SOM, State Operations Manual, Survey Instructions, Survey tasks, Surveyor
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