How A Hospital Surveyor Conducts The Hospital Survey - Part 3
In the previous posts we started talking about how a nursing home and hospital surveyor conducts a hospital survey and the various steps, or tasks, involved. We are up to task 3.
Task 3, the Information Gathering and Investigation phase, focuses on actual and potential patient outcomes, as well as the processes the hospital is required to have in place. It is during this time that the Hospital Survey team assesses the care and services provided to the patients. The Hospital Surveyor will visit all the patient care settings, including inpatient units, outpatient clinics, anesthetizing locations, emergency departments, imaging, rehabilitation, remote locations, satellite locations, etc. The members of the team will observe the actual provision of care and services to patients in every area of the hospital and the effects of that care. The team constantly communicates with each other in order to determine if they have any critical issues. The survey team members can also decide to have a hospital staff member accompany them or to go about the facility without an escort. Personally, I usually find it prudent to have staff come with me for several reasons. They can answer my questions or find someone quickly who can, they can get me from one unit or area to another without me needing a map, and they are witnesses to issues I find as I go about the hospital. If I want to privately interview a staff, patient, or visitor, I ask the accompanying staff to leave.
As an aside right here, I find it quite annoying when there are 6 or 8 staff following my every move. Several questions come to my mind in those instances:
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Who is caring for the patients if there are 6 or 8 people following every surveyor
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What are they afraid I will find that they want 6 or 8 people following me around? One staff accompanying me is enough, and sometimes two is OK as one can go find an answer to a question while the other continues to go around with me.
I will say, it is interesting (and funny) to see staff “scurry” when a hospital surveyor approaches. I remember on one survey how I was going around with 1 staff member and there was another who kept disappearing around the corner every time I turned around. I wonder if she thought I didn’t notice her disappearing every time I turned around.
The hospital staff often have many questions and will ask a hospital surveyor for his or her guidance on how to correct a problem. Because the team is a representative of a regulatory agency, it is not in the role of a team member to provide consultation. Some states, though, do allow some limited consultation with the facility. The problem is that the hospital or facility then says, “But the state said……”
The hospital surveyor will also do a comprehensive review of care and services received by each patient in the sample. A comprehensive review includes observations of care/services provided to the patient, patient and/or family interview(s), staff interview(s), and medical record review. Observations provide first-hand knowledge of hospital practice and provides valuable information about how the care delivery system works and how the hospital’s departments work together to provide care. Interviews provide a method to collect information, and to verify and validate information obtained through observations. Document review focuses on a facility’s compliance with the Conditions of Participation. Documents reviewed may be both written and electronic and include but are not limited to patient?s clinical records, personnel files, credential files, maintenance records, staffing documents, policy and procedure manuals, committee meeting minutes & records, and contracts.
In the next post we will continue with our discussion of the steps and processes that a nursing home and hospital surveyor follows when conducting a hospital survey.
Filed Under Hospitals, Regulations, Survey Task |
Tagged With Hospitals, SOM, State Operations Manual, Survey, Survey Instructions, Survey tasks, Surveyor
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