I always get a kick out of doing my year in review. Did I meet my personal and professional goals? Did our clients improve their outcomes? Were new relationships established and old ones strengthened? 

You probably do a similar review. Does it include a look at your survey and regulatory performance in 2013? Let me give you a hand. 

Over the past two years, the average total number of deficiencies, standard survey and complaint combined, has improved slightly to 6.86. Just counting standard survey, the number is 5.77.  

However, negative trends in G-level deficiencies, immediate jeopardy and substandard quality of care deficiencies were seen,  particularly in some CMS regions and states. 

Let’s take a closer look.

Throughout the country, the average number of facilities with a G-level citation (17%) has slightly improved. 

Hats off to Region 4 for improving to well below the national average (10%).

Region 5, thanks for lowering your rate to 21%, but there’s still more work to do. 

Region 9 has seen a 3% rise in facilities cited at the G level over the last two years. These deficiencies, we find, are being generated from complaint surveys in survey districts concentrated in California. (I’ll address surveyor district variations in a future online blog; perhaps the title will be “Seriously?”)

So how did you do? How did you compare to the nation? How about your CMS region or state? 

If you fared better on standard surveys, which are anticipated and planned for, but had more complaint deficiencies, the response is clear.

Identify the catalysts for the complaints and your overall complaint management process. This disparity in performance suggests that the good work you do in survey readiness should be extended to every day practices. It’s a philosophical shift and a perfect opportunity to undertake a Quality Assurance and Performance Improvement initiative.