Compliance with confidence

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Compliance with confidence

Undergoing the annual survey and certification process and demonstrating compliance with federal and requirements are a critical – and sometimes daunting – obligation of any nursing home operator participating in the Medicare and Medicaid programs. Not only can shortcomings result in deficiencies and fines, noncompliant facilities also may be denied payment for new admissions or face revocation of Medicare and Medicaid certifications.

The purpose of the survey and certification process is to assess whether quality of care is being delivered in the nursing home, and in accordance with rules, regulations and resident need. It also aims to ensure that any deficiencies are promptly and adequately addressed. To that end, it is incumbent upon the operator to substantiate the care provided through diligent, thorough documentation and demonstrated regulatory compliance.

“This survey process serves as a primary driver for the CMS Five Star Quality Rating System, so it's important to be able to identify potential problems and trends, and compare your facility with others to get a better picture of your risks for deficiencies and other [negative outcomes],” said Steve Biondi, RN, vice president of clinical services and corporate quality officer for Extendicare Health Services Inc.

Running down risk

No question, having processes and tools in place to help facilities keep a finger on the pulse of their risks and opportunities, for improvement will pay big dividends. As the public has grown more sophisticated in its ability to access and review information on the Internet, prospective residents and their families are using survey ratings and quality scores to winnow down facility options and drive more word-of-mouth referrals. A higher quality rating and a more positive public perception also may largely factor into an acute care system's desire to partner with a particular long-term care facility.

“As we move toward bundled payment and accountable care to manage a group of patients across the care continuum, our rating and how we're perceived will become a very important deciding factor,”  Biondi noted. “To survive, we'll have to stay competitive and focused on quality.” 

Of course, survey ratings also play into an operator's liability risks. If a resident falls and breaks a hip, for example, and a claim arises, a plaintiff attorney will be looking closely at the facility's survey rating to determine whether or not it could be used to substantiate the claim. “Even if a facility did all the right things to prevent the incident, the rating could work for or against you,” Biondi noted. “This is just another reason why it's vital to have the ability to look at yourself, see how you're doing in comparison with others, and know where to focus your improvement.”

Competitive advantage

While any long-term care operator can access public quality and performance data, they will likely lack the resources to perform meaningful competitive analyses internally to evaluate risks and effectively compare their quality performance with similar facilities nearby or across the region or state. To help facilities fulfill this critical need, PointRight Inc. developed the Survey & Certification Competitive Analysis – a sophisticated tool that relies on data analytics to drive more informed decisions about clinical, claim and litigation risk.

SCCA offers facilities a choice of two reports, each of which provides substantive data to deliver a reliable snapshot of where they stand and what they need to do to improve survey results, public perception, occupancy and referral rates. The Survey and Certification Competitive Analysis provides a comprehensive overview of where a facility is at any given time. The Survey and Certification Competitive Analysis with Survey Risk Profile provides a current overview and predictive preview of what's likely to happen in the next 12 months, along with specific corrective actions to prevent negative events from occurring.

Authenticating performance

The SCCA tool's strength also lies in its ability to provide specific and tailored benchmarks, so facilities can know their performance in their survey district compared to their exact peer group.

“This is hugely important in survey and certification because every survey district is so different – and may even differ from the one just around the corner or down the street,” explained Steven Littlehale, EVP and chief clinical officer at PointRight Inc. “In fact, the number one predictor of survey results is your Zip code and which surveyor will be walking through your door.”

Having that comparative data provides a window into a facility's authentic performance. Facilities can then get a clear view into what it will take to make it into the top 10% of their peer group, for example, while historical performance data allows them to isolate their greatest risks and challenges.

“Maybe it's a problem on the standard survey or how that facility deals with families, for example – or maybe they're not following good enough care processes. Whatever the case, SCCA can help drive down to the root issue,” Littlehale continued. “We can then combine historical data with predictive analytics to say, ‘Based on what's going on with your survey today and where you were in the past – and also on current trends and citations that we're seeing with other facilities in your area – here are the top hot spots that you're likely to be cited for during the survey.'” The report then prioritizes those problem areas according to greatest risk, so facilities can quickly and easily determine which should be addressed first.

Seeing the big picture

PointRight's ability to blend highly sophisticated, detailed data analytics capabilities with an easy-to-decipher-and-navigate reporting function is another significant benefit, added Biondi. The tool provides a color-coded snapshot that escalates from green (good) to yellow (areas that may be in need of a closer look) to red (areas presenting the greatest risk), so staff time and resources can be most effectively allocated.

“The reports are very detailed, yet pictorial and intuitive. A layperson can look at it with very little coaching and make sense of it. This is important because great data will be wasted if it's a challenge for people to use,” Biondi said.

Although using the SCCA to earn a better Five Star Quality Rating may be what initially attracts facilities, he has seen firsthand how the benefits extend far beyond that.

“This tool can be very useful in widespread quality assurance/quality improvement processes and looking at trends relative to complaints or allegations. It can provide a lot of clues to help you discover what's driving a problem or exception,” he explained, adding that a facility may discover that the right process wasn't in place to drive a desired result – or, perhaps, that the process was good, but staff weren't adequately educated on that process to apply and monitor the right interventions.

“Having a tool like [the SCCA] that lets you use retrospective and predictive data to drive improvements will ultimately lead to better care for our residents,” Biondi said. “And when that happens, you can bet that a better score on that universal report card will follow.”


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