How to Plan, Prepare & Survive a UHMS Survey Janet H. Bello, RN, BSN, ACHRN Hyperbaric Consultant UHMS Nurse Surveyor Why Accreditation? • Joint Commission recognizes the UHMS as a complementary accrediting body. body • UHMS is one of only five organizations so recognized. • Insurance requirement i t t iin thi • more interest this area every year • Marketing M k i S G l Survey Goals  Clinical hyperbaric facilities are: Staffed with the p proper p specialists p who are well-trained  Using quality equipment that has been properly installed and maintained, maintained and being operated with the highest level of safety possible P idi high hi h quality li off patient i care  Providing Maintainingg the appropriate pp p documentation of informed consent, patient treatment procedures, physician involvement, etc Plan  Cost –  Application fee- $495  Survey fee- $4500 plus all expenses for surveyors  Estimate- $8000 to $10,000  Who to involve? EVERYONE!!  Staff & p physician support y pp necessaryy  Hospital administration also important  Documentation comes from all areas  Unit U it  Hospital, Safety Officer, Medical staff office, Facilities manager  Contractor Process  Application & Pre-survey Pre survey Questionnaire  Defines the Legal entity  Overview of unit  Introduction to types of information required  Survey date assigned  Timing  Start preparation at least six months prior to survey date Expectation  DOCUMENTATION DOCUMENTATION, DOCUMENTATION !!!!  Not documented, not done  You will kill a few trees!  Education  Surveyors y want everyy unit to achieve accreditation!!  Continuity  On ggoingg p processes  Integration  How does the unit, contractor, hospital p interact from topp to bottom  Unit specific Policies/Procedures/Quality Improvement The Accreditation Manual is your guide Survey Probe Reference Acronyms:  AAAHC Accreditation Association ffor A Ambulatory Health Care A d A b l H lhC  ASME American Society of Mechanical Engineers  ANSI American Standards Institute  BNA Baromedical Nurses Association  CGA Compressed Gas Association  CFR Code of Federal Regulations  HFG UHMS Guidelines for Hyperbaric Facility Operations, Undersea and Hyperbaric Medical Societyy y  JCAHO Joint Commission for Accreditation of Health Care Organizations  MPCS Manual of Patient Care Standards  NFPA National Fire Protection Association  PVHO Pressure Vessels for Human Occupancy References f y Standard For PressureVessels For Human  ASME PVHO-1-2002,, Safety Occupancy; American Society of Mechanical Engineers  ASME PVHO-2-2003, Safetyy Standard For PressureVessels For Human Occupancy In-Service, Guidelines For PVHO AcrylicWindows; American Society of Mechanical Engineers  NFPA 99, Health Care Facilities,(2005 edition); National Fire Protection Association G id li for f H b i Facility F ilit Operation; O ti Undersea U d  UHMS Guidelines Hyperbaric andd Hyperbaric Medical Society  Guidelines For: Standards of Care For The Patient Receiving Hyperbaric Oxygen Therapy; Baromedical Nurses Association  CGA P-2-1996,, Characteristics and Safe f Handlingg off Medical Gases;; Compressed Gas Association, Inc. Twenty-four y concentration areas and their probe code: • HBOG - Hyperbaric Governance H b G • HBOA - Hyperbaric Administration • HBOO - Hyperbaric Operations • HBOM - Hyperbaric Maintenance • HBOC - Hyperbaric Facility Construction • HBOF - Hyperbaric Chamber Fabrication • HBOV - Hyperbaric Chamber Ventilation • HBOFP - Hyperbaric Chamber Fire P t ti Protection • HBOE - Hyperbaric Chamber Electrical Systems and Services • HBOGH -Hyperbaric Hyperbaric Gas Handling • HBOPR - Hyperbaric Patient Rights • HBOPA - Hyperbaric Patient Assessment Blue=Physician/ Red=CHRN/ Black=CHT • HBOPC - Hyperbaric Patient Care H b P C • HBOEC - Hyperbaric Environment of Care • HBOPE - Hyperbaric Patient Education • HBOQI - Hyperbaric Quality Improvement • HBOPI - Hyperbaric Professional Improvement p • HBOL - Hyperbaric Leadership • HBOHR -Hyperbaric Human Resources • HBOIM - Hyperbaric Information Management • HBOIC - Hyperbaric Infection Control • HBOMS -Hyperbaric Hyperbaric Medical Staff • HBOTP - Hyperbaric Teaching and Publication • HBOCR -Hyperbaric Clinical Research R ti Guide G id Rating g 0 -Non-conformance f  Rating .  The hyperbaric facility does not even partially conform to the major provision of the standard or its intent. When a rating of 0 is assigned, a recommendation must be made that addresses the requirement. Suggestions for achieving conformance may be included in the recommendation.  Rating 1 -Partial conformance.  The hyperbaric facility meets some of the provisions of the standard and its intent, yet does not y When a ratingg of 1 is assigned, g a recommendation meet the standard or its intent in its entirety. must be made to explain what the facility should to do to be in full conformance with the requirement.  Rating 2 -Conformance.  The hyperbaric facility fully meets the provisions of the standard and its intent. No recommendation or comment is required.  Rating g 3 -Exemplary p y conformance. f  The hyperbaric facility significantly exceeds all provisions of the standard and its intent. A statement must be provided to justify the assignment of an exemplary notation.  NA - Not applicable pp Preparation  Make a Timeline  Can’t start soon enough/at least 6 months prior  Set aside about an hour p per dayy to start  Delegate  Review the Accreditation manual  There are about 500 probes to be met  Each probe is color coded to indicate the chamber classification emphasis  Light Gray = Class A hyperbaric ffacility only- multiplace  Dark Gray= Class B hyperbaric facility only- monoplace  White =All hyperbaric facilities  Identify any probes you cannot currently document  Determine what is needed to meet the probe  New or updated p ppolicy, y pprocedure or forms  Start new documentation to show continuity  Decide how to present your documentation  Notebooks, Notebooks Hanging files, files File boxes  One notebook/folder for each concentration area is best  Make it easy for the surveyors to find information!  Concentration areas are divided among the surveyors:  Ph Physician-Governance/Patient i i G /P ti t Ri Rights/Patient ht /P ti t C Care/Professional /P f i l Improvement/Leadership/Medical Staff/Clinical Research  CHRN-Administration/Patient Assessment/Patient Education/Quality Improvement/Human Resources/Information Management/Infection Control/Teaching & Publication  CHT-Operations/Maintenance/Construction/Fabrication/Ventilation/ CHT Operations/Maintenance/Construction/Fabrication/Ventilation/ Fire/Electrical/Gas Handling/Environment of Care  Consider & reserve a location for the surveyors y to work  Look for overlapping probes in various areas. p  Manyy probes are the same but found in different areas  Gas handling probes are in Administration (HBOA)- HBOA 7.0 Rules and regulations on the safe handling of gases in the hyperbaric facility are developedand in a separate concentration Gas Handling (HBOGH). (HBOGH)  Safety Director role noted in physician, nurse & tech probes  Surveyors look for the same standards with different eyes- tech, nursing & medical d l  Don’t forget integration! U specific f policies/QI l /QI  Unit  Meet with other hospital departments  Give Gi them h copies i off the h probes b to bbe documented d d  Senior management means hospital administration/contractor administrators  Don’t assume-documents required p  HBOA 1.3 Policies and procedures are established to validate that all reasonable efforts are being made to comply with all applicable laws, regulations, codes and standards  HBOG 2.17 2 17 Th The governing i bbody d ensures th thatt th the hyperbaric h b i ffacility ilit complies with the requirements of the Americans with Disabilities Act of 990.  Make it easy on the surveyors  Don’t make them hunt for policies-provide a copy of the policy  But keep it simple  Six pages not necessary if one section of policy answers probe  Not interested in proprietary information  Just supply section appropriate to probe  Don D ’tt fforgett thi thirty t dday posted t d notice ti tto patients! ti t ! Two Weeks To Go  Review survey schedule  Complete organizing material  Confirm C fi conference f room reservedd  Clear Medical Director schedule  First day AM & second day PM  Invite Administration personnel  Facility Overview at 8AM first day/Outbrief on second day about 2-3PM  Prepare Facility Overview presentation (optional)  Arrange g pprojector j for Administration Outbrief One Week  Last review of documentation  Organize materials for surveyors-P&P books etc  Remember “nobody’s perfect”-too late to make major changes now  Order lunch for first day  Surveyors usually prefer to work through lunch on first day  Arrange visits with other departments  Physician y visit to Medical staff office to check credentials  CHT to view O2 exhaust site (get to roof?)& visit oxygen farm  Find out if any patients want to speak with surveyors The First Day  Take a deep breath-you breath you are ready!!  Meet surveyors at main entrance/Stop at security?  Remember educational not confrontational  Surveyors questions are usually for clarification -not criticism  Everyone has their own way of doing things  Verbal explanations/information counts  Provide a comfortable location  Out of unit flow  Large enough for 3 laptop computers & all documentation  Able to be private & secured  Extra pens & sticky note pads helpful  Schedule y arrive the night g before at hotel  Surveyors  Will check to see how emergency HBOT calls are handled after hours  Unit visit starts at 8 AM & lasts until 4:30-5PM  Introductions  Facility overview  Light breakfast?  Unit tour  Review your documentation presentation  Have a hospital computer available if some policies are p intranet on hospital  Be available but keep busy  Maintain usual unit p patient schedule  Physician & Medical Director meeting  Chance to discuss Medical Director’s Director s wish list  Safety Director & CHT  Review R maintenance/safety/construction / f /  Visits to unit by surveyors separately & together  Clarification/Confirmation  Chart reviews  About six charts  Current & discharged  Wounds & non-wound diagnoses Second Day  Observation in unit in AM  Chart reviews- if not done  Surveyors final review & preparation for Outbriefs  May need assist with projector & copying  Outbrief to Medical Director  Verbal V b l with i h paper fformat  Some include other staff  Outbrief Outb e presented p ese te to Administration st at o  PowerPoint presentation  Only the highlights presented  Outbrief to staff  Verbal with paper format  U ll iin unit Usually it /ti /time ffor di discussion i It Is Over!! Relax & celebrate!! Follow Up  The Accreditation Council returns a decision about thirty (30) days after the survey is completed  The survey team is only collecting information. They do not render d a preliminary li i or fifinall accreditation dit ti ddecision i i andd no indication of success measured against the total accreditation process will be provided.  After the on on-site site survey, survey the Accreditation Council will carefully review the surveyors report, supplemented by other relevant information prior to making a formal accreditation decision. Accreditations  Full Accreditation (3 years)  Assessed conformance with minimum standards that all non affiliated, hospital affiliated, and hospital-based hyperbaric facilities are expected to meet  Accredited with Distinction  Clearly demonstrating the minimum conformance has been exceeded in specific activities deserving the added recognition as hyperbaric community leaders  Deferred Accreditation (up to 12 months)  It is not the intent of the UHMS to deny accreditation to any hyperbaric facility without allowing sufficient time for the specific issues identified in the Accreditation Survey Report to be resolved  A certificate ifi off accreditation di i will ill bbe iissuedd after f allowing ll i time i ffor the h hhyperbaric b i facility to successfully address specific issues identified in the Accreditation Survey Report Questions or Comments?