Survey Preparation Carrie Bradford MHA RHIA CPMSM CPCS

+ Survey Preparation Carrie Bradford, MHA, RHIA, CPMSM, CPCS Judy Eastridge, MBA, CPMSM Stephanie Russell, BS, CPMSM, CPCS

+ Basic Information n Accrediting Body n TJC n NCQA n DNV n HFAP n CMS n AAAHC

+ Who’s Leading the Team? n Know Your Role n Participative n Supportive n Clear Expectations n Organizational Resources

+ TJC n Self Assessment – Focused Standards Assessment (FSA) n n Myopic hazards! Document compliance n Findings versus RFIs (Requirement for Improvement) n Other

+ Where Are the Answers? n Methodical n Identify BY Standard YOUR Compliance n Bylaws n Policies

+ TJC n Not Just Medical Staff Standards n Leadership n Human Resources n Infection n Other?

+ Variability n By Surveyor n By Location n n Ambulatory n Hospital n Disease Specific (this should be scheduled) Focused Standards Assessment

+ Surprise – We’re Here n TJC “usually” includes Credentialing in Every Survey n CMS “usually” does also n They May Follow Each Other n Physician Leadership Interview n n Who should participate? Quality process/leadership

+ Deemed Status n CMS Validation n Follows TJC Survey n More Routine now than ever n Co. Ps and EPs

+ Horror Stories

+ Dreams Come True

+ Questions