Healthcare Management Solutions, LLC (HMS) State Operations Director Polly Weaver, Health Facility Surveyor Sharon Whitehead, and Subject Matter Expert Kristen Paulsen-Aguirre delivered a webinar on October 20, 2020, focusing on “Quality Improvement Strategies for Surveying Infection Control” for the Association of Health Facility Survey Agencies (AHFSA) Virtual Engagement Series. The experienced trio of survey leaders on infection prevention and control in nursing homes presented a four-part program covering Long-Term Care (LTC) Survey Infection Control Review, COVID-19 Focused Surveys Review, Non-Long-Term Care (NLTC) Survey Infection Control Review, and Survey Quality Assurance.
The webinar provided participants with an in-depth review of eight key elements essential to understanding survey quality improvement:
- The purpose and hypothesis behind the data analysis project
- The method of data collection and analysis for this project
- Results of the data analysis
- Opportunities for surveyor growth indicated by the data analysis results
- Oversight authority related to Quality Assurance Quality (QA) Reviews
- Process for conducting QA Reviews
- Use of available QA Review Tools
- Documentation management
The HMS research included infection control citations and practices for both Long-Term Care and Non-Long-Term Care facilities.
Findings from this research reflected that surveyors have a pervasive misunderstanding of investigative techniques related to infection control concerns, and deficiency writing including identification of the appropriate scope/severity or level of the deficiency. In addition, while surveyors typically noted LTC facility practice failures in the areas of hand hygiene, resident or patient care (i.e., wound care, catheter care, incontinence care, etc.), and transmission-based precautions, systemic issues in facility infection prevention are not investigated or cited and pertinent observations and interviews are not conducted as appropriate.
These findings suggest a need for additional training for survey staff on investigation procedures, documentation, and deficiency writing. In addition, strengthened internal Quality Assurance systems would improve the quality of the survey product prior to issuing the report and verifying that a thorough investigation was conducted and that the report is accurate and appropriately written.
For more information on this webinar presentation and its findings, contact HMS here:
- Email: Proposals@hcmsllc.com
- Phone Number: 304-368-0288