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The turnaround to survey excellence

February 17, 2012
by Jaime Todd
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Begin now to improve your survey results

Peter Ducker, one of the most renowned management minds of our generation, offers this observation:“Good intentions don’t move mountains, bulldozers do!” If your facility repeatedly receives poor surveys, it’s time to bring in the heavy management equipment and get everyone motivated to bulldoze the way to better results.

Survey excellence should be a professional goal of all healthcare workers. Passing surveys is a healthcare worker’s job. Sometimes people forget that once hired, they are there for the job, not the other way around. They must do whatever is necessary to protect the well-being of the residents and maintain the facility’s good reputation. It takes relentless planning, consistency, good follow-up and ongoing education to keep everyone at optimal job performance.  In the following article, I suggest a three-step approach to encouraging complete staff involvement: the Focus Review, the Fast Track and the Survey Prime.


Dissect the survey findings. Department heads must immediately be assigned to a meticulous study of the survey findings and, subsequently, identify all regulatory/policy violations cited within their compliance jurisdiction. Key staff should also be assembled into a drop-down team whose job is to ensure a future compliance review and establish corrective action.

During the first read-through of the CMS 2567 Statement of Deficiencies, pay close attention to those staff singled out in the findings. Quickly schedule face-to-face meetings with them so they can either confirm or dispute the findings. Surveyors do make mistakes when citing deficiencies and those mistakes should be noted by your facility and clearly outlined in the plan of correction (POC).

However, when staff is directly connected to a deficiency, address those matters immediately. This part of the process is not about sparing any feelings or not upsetting sensitive colleagues; it’s about a logical, professional approach to giving staff information they must have. During face-to-face meetings, educate those staff as to the proper procedures to follow regarding the regulation/policy in violation. Requirestaff to sign a training form that has a copy of the regulation/policy attached. Repeat this process for all staff singled out in the CMS 2567.

The next phase of the focus review includes departmental and global (all staff) training. Each training module should be set up to include an overview of regulations/policies violated, as well as the following four key elements:

  Corrective action.Discuss in detail how the deficiency was corrected.

•  Procedure used for identifying other residents potentially affected.Deficiencies generally affect all residents. Staff should be told how the facility identified whether other residents were impacted by the cited deficiency.

•  Systemic changes.Discuss how the facility implemented changes to minimize the recurrence of the cited deficiencies.

  Quality assurance (QA) monitoring.Discuss how the facility audits corrective actions to hold staff accountable for implementing the POC effectively.

The most effective way to develop a quality allied healthcare delivery model in long-term care is to bathe staff in an intensive, focused review of information regarding regulations, facility policies and procedures, and innovative LTC operations until it becomes second nature to staff. Then—and only then—will core competencies emerge and survey outcomes improve. It’ a matter of time, consistency and diligence. Inspire staff to do their best to get the best surveys possible.


Prepare for the resurvey; get the drop-down team in action. Once the POC is accepted by the Department of Public Health (DOPH), immediately execute a Fast Track in preparation for the resurvey. The Fast Track is a deconstruction of the POC and it requires the following key elements: POC analysis and planning, discovery and content edification.

The drop-down team is responsible for Fast Track’s implementation. In the analysis and planning phase the team must develop auditing tools to assess compliance as outlined in the POC under QA monitoring. Consider this example of a common deficiency in the area of privacy:

The surveyor observed that staff were not knocking or announcing themselves before entering resident rooms. The immediate corrective action was to provide refresher training to all staff relating to policies and regulations relating to privacy, resident rights and maintaining resident dignity. The QA monitoring in the POC called for weekly, unannounced 15-minute observations of the nursing units to determine if staff was following proper regulations/policies regarding resident privacy.

Assume that it took five weeks for the DOPH to accept the POC. The drop-down team member assigned to nursing would first check the prior five weeks of audits to assess compliance and make adjustments as needed. Then the drop-down team member rigorously conducts his or her own 15-minute observation as outlined in the POC. This same process is completed for each deficiency and conducted by the various drop-down team members. The findings are documented and prepared for “content edification.”