Get Survey Ready with Remote Review 60
MVP Consulting Group is proud to offer healthcare Governing Boards and Leadership Teams the opportunity to improve the quality and regulatory compliance of the most common High Priority documents requested for review by all accreditation survey teams. Our mutual goal is for your Leadership Team to engage in your survey with confidence.
The fuller description of our High Priority Remote Review 60 extends far beyond just reading. Yes, in part, we accomplish our mission on behalf of our clients by reading each document. But also by cross-referencing multiple ‘related’ documents, comparing document content to related regulatory standards, assessing performance over time as reflected in our review of related PI and Quality measurement data and meeting minutes.
Beyond just reading, the Remote Review 60 is an analytical process delivered by MVP’s experienced survey prep specialists.
The Value of Remote Review 60
- Having current and compliant documents is the foundation to have current training approaches, performance monitoring and improved staff performance. And survey success.
- Our Remote Review 60 will save your organization 70-80 hours of professional time which we will dedicate, on average, for a 60 document review.
- The results of our Remote Review 60 are reported to you, with recommendations for improvement, as needed, for all documents reviewed.
- You will also receive a highlighted notice if any document assessed must undergo fairly significant updating. That being updating to the degree that perhaps certain processes or procedures will need to also be updated in HR’s General Orientation, or Department-specific Orientation programs, or position descriptions, or added to Quality / PI measurement dashboards, etc.
- We fully understand that the caliber of our clients’ plans, policies, procedures, and/or data measurements must be in alignment with the activities included in all related staff orientations, position descriptions, and competency tools.
Three (3) Remote Review Service Options
As a Remote Review Client, you will have access to three (3) service options:
- You are welcome to select sixty (60) of your current documents that you wish MVP Consulting Group to review and report the compliance status of each document.
- Sixty (60) of the highest priority documents that are very likely to be requested during your upcoming survey, as identified in the three (3) Priority Packets below.
- A combination of some of your organization’s current documents substituting for some of the 60 document titles suggested in the Priority Packets below, maintaining the total goal of 60 documents to be transmitted to MVP for Remote Review.
Why Surveyors Will Request to Review Documents
It should come as no surprise to any healthcare leader that, when undergoing either a Joint Commission (TJC) survey or a Centers of Medicare & Medicaid Services (CMS) inspection – both professional entities will request to review scores of your organization’s documents. These document requests should never be assumed to indicate that either organization is ‘out to get you’.
30+ years of survey preparation experience refutes that unsubstantiated notion completely
In addition to determining if the documents are compliant with current standards, the core reason your documents will be reviewed is for the surveyors to be better positioned to synthesize the verbal responses offered by your staff during their tours, conference room meetings and tracer-based interviews.
Document Review and Reporting Process
In summary, we commit not only to fully review each individual document that our clients provide for our counsel. As relevant, each document will first be cross-reviewed against the current year’s TJC and CMS Standards – and scored accordingly. Additionally, all suitable documents will then also be cross-reviewed with other topic-related documents provided.
For example:
- First review each of the written Environment of Care, Life Safety and Emergency Management Plans, cross-referenced with the applicable EC, LS or EM Standard or EP.
- Then review the current YTD Summary of the Performance Improvement (PI) data findings that have been collected and documented for all of the safety-based Plans noted above.
- Assess whether these PI measures – and the data findings – are in harmony and correlate to the expectations (Elements of Performance [EP]) reflected within the related Plan’s safety-based standards.
- Report our assessment Findings and Recommendations to our client for each document reviewed.
There are many other examples of the cross-assessment reviews that we will perform.
Another example:
- First review and assess the organization’s Infection Prevention Plan to confirm the Plan is in compliance with current IC Standards.
- Then review the expected Infection Prevention Performance Improvement (PI) data and metric dashboards, which should represent the improvement targets and up-to-date performance data.
- Understanding this information, the next step is to review two (2) consecutive sets of Infection Prevention Committee’s meeting minutes. As the IC Committee leaders are chiefly responsible for all infection reduction activities, the meeting minutes should reflect that they are receiving current and relevant IC data and information. These IC meeting minutes should also reflect what the committee thinks about the information and data that is being presented. Key themes being sought are Action and Improvement.
Yet another example would be the Medical Staff Bylaws that every hospital is required to have available for surveyor review. For the Medical Staff Bylaws to be rated fully compliant with the Joint Commission standards, they must meet the compliance requirements reflected in four (4) separate MS standards. And the first standard alone (MS.01.01.01) requires that all 38 Elements of Performance (EP) meet documented requirements and thus not be cited as non-compliant. That’s 38 EP’s for just one (1) standard.
MVP Consulting Group’s Qualifications
Our MVP Consulting Group’s Principal, Mr. Garry M. Walsh, will perform all remote document reviews, assessments and generate all recommended action plans to help resolve any matters identified during the document assessment.
A snapshot of Mr. Walsh’s survey preparation experience is best summarized as the following:
- Previously the owner and manager of two (2) national healthcare service corporations (1988 – 2020) solely engaged in preparing Medical Centers, Behavioral Health facilities and Ambulatory facilities of all settings for their surveys.
- Proudly served healthcare facilities in 36 States
- Blessed to have traveled for 32 Years
- Tiredly flew 1.8 million miles
- Also served as a Healthcare Policy and Regulatory Expert Witness on healthcare injury legal cases. (18 Depositions, 2 Court Appearances).
Your Survey Success is Our Only Goal
Based on many years of the MVP Consulting Group helping our healthcare facility clients prepare for surveys / inspections, all MVP Consulting associates know one thing for certain. That being, if our client fails a survey… so do we. And we are not going to start now.
No MVP Consulting Group client facility has ever been denied TJC or CMS accreditation as a result of a negative survey experience after receiving our pre-survey consultative support.
