Posts Tagged ‘Medical Facilities’

Evidence-Based Decision-Making: A Key Regulatory Benchmark

November 19th, 2012

The role of a surveyor can be a difficult one. Our team of licensing surveyors need to maintain neutrality as regulators and be able to apply the Arizona Administrative Code (otherwise known as “the rules”) to a wide variety of facilities within the healthcare system.  Part of our surveillance includes investigating complaints- which can be generated from an array of internal and external sources.  When the complaints come because of TV or other media coverage- it can pose unique challenges for our team.  But…  no matter where the complaint comes from, our job is to use facts and evidence to drive our investigation, decision-making, and interventions. 

There are 3 forms of evidence that we use to substantiate an allegation made in a complaint: 1) observation; 2) documentation; and 3) interviews. Two of these forms of evidence need to be present before we find that a complaint is “substantiated”.  By using these tried and true evidence-based tools we put ourselves in the best position to identify real health and safety problems without jumping to conclusions.

Focusing on facts and evidence (and not allowing one’s self to be driven by media coverage) is a good start…  but there are a few things that both surveyors and healthcare professionals can do to keep focus on providing a healthy and safe environment. Keep good records, document, sign and store up to date data, maintain consistent supervision for those that require it, follow your agency’s policies and procedures without fail, report what’s required, be proactive (not reactive), and seek out ongoing education in your field.  Don’t cut corners when it comes to care… and don’t be afraid to admit a mistake or that you do not have all the answers. 

So, if you happen to hear or see a TV story about a facility, keep in perspective that the story might focus on anecdotes and what the reporter thinks they know or even just their opinion- not necessarily what the evidence demonstrates.  In a time when information is disseminated second by second rather than day by day, let’s remember that we all share the same goal, to promote Health and Wellness for all Arizonans, which includes providing surveyors, community, clients and staff accurate and factual information.

Curious about the real scoop on how all of our licensed facilities are doing?  Check out our AZ Care Check website which has the details about our evidence-based investigations and surveys.

Interim AD for Licensing

May 10th, 2012

 Colby Bower will serve as our Interim Assistant Director for Licensing while we recruit and hire a permanent Assistant Director.  Colby has been serving as our Legislative Affairs chief for the last couple of years.

Colby fills several of the criteria that we needed for the interim post: 1) He’s a good risk manager and has a good understanding of the importance of Stakeholder relations; 2) He understands the matrix of our statutes and rules- and knows that we need to exercise our authority through the prism of public health; 3) He’s good with people; and 4) Now that the legislative session is over- he’ll have the time needed to invest in the program.  Our Operations folks are busy doing all of the IT, finance and legal things to get Colby the authority and tools he’ll need in his post.

We’ve already announced our recruitment for a permanent Assistant Director.  I blogged about the recruitment yesterday, including a hot link to the job announcement on ADOA’s website.  Our goal is to complete the recruitment process and hire a permanent AD this summer.

 

Join me in welcoming and thanking Colby for his willing to fill this important post while we go through the full recruiting process!

ADHS Looking for a Forward-thinking Assistant Director

May 8th, 2012

Promoting Health and Wellness for all Arizonans” is the motto of the Arizona Department of Health Services.  We promote and protect the health of Arizona’s children and adults and set the standard for personal and community health through direct care, science, public policy and leadership.  Want a piece of the action? 

We’re looking for an experienced and proactive leader to become our new Assistant Director for Licensing Services. This key position reports directly to me and manages six different state and federal licensing units including Long Term Care, Medical Facilities, Child Care, Assisted Living, Behavioral Health, and Special Licensing.  The job oversees about 200 employees and a budget of $17M.  But- what makes the job exciting is that you’ll have a unique opportunity to lead a dynamic team and use your talents and skills to make Arizona a healthier place- “Promoting Health and Wellness for All Arizonans”.

AZ Carecheck

November 14th, 2011

It’s been a while since I mentioned to you that our Division of Licensing has a really good web site called AZ Care Check.  Our website provides a 3 year history of survey results, complaint investigation results and if any of our licensed facilities (nursing homes, assisted living, hospital and other medical facilities, childcare or behavioral healthcare services) including any enforcement actions in the last 3 years. 

AZ Care Check also provides the user with facility names, addresses, city, phone number and other useful pieces of information. In fact, once you select a facility to review, you can even be linked right to MapQuest to get directions. Of course, the main value of this website is to provide the user with up to date information about our licensed facilities so a good decision can be made when services/care are needed.  I encourage you to visit the website and to pass it along to someone you know who may find this website useful.

A Look in the Mirror

September 15th, 2011

Many folks don’t know that our Licensing division undergoes a periodic audit (survey) to look at compliance to our Federal contract with the Centers for Medicare Medicaid Services (CMS). This past week, 3 surveyors from the regional office of CMS came to review our Long Term Care and Medical Facilities areas. This survey centered on complaint surveys and their prioritization, initiation and investigation. This audit is much like the surveys the Division of Licensing performs on our licensees. There’s an “entrance” whereby the Surveyors explain why they’re here, what they’re going to look at and items that they’ll need in order to help them with their survey. Then there are a few days of what can be intensive record review, interviews with staff and other associated investigatory activity. 

Then the Surveyors compile their information and hold an “exit” with the staff to review what they did, found and suggestions from the survey. During this, exit the staff finds out areas the Surveyor reviewed and if there are any areas they will need to improve upon (findings).  CMS asks for a plan of correction where we would provide a description of how the issue(s) will be resolved, when they’ll be resolved and how we’ll maintain and monitor things.  

Lots of hard work goes into preparing for these CMS visits. Thank you’s go to everyone who work in the Bureaus of Long Term Care Licensing and Bureau of Medical Facilities Licensing. It is truly a team effort as CMS looks at the field work/documentation of the Surveyors, the reviews of the Team Leaders and Bureau Chiefs and the documentation files etc. the Program Project Specialists and the Support Staff maintain.  We don’t have our report back yet- but all indications are that we did well on our assessment.