Last September the Arizona State Hospital (ASH) was inspected (surveyed) for the Centers for Medicare and Medicaid Services (CMS). The survey team can review over 20 different areas and three were identified that we needed to address: Governing Body, Patient Rights, and Nursing Services.   In December, we developed and implemented a Plan of Correction which was submitted to CMS.  Some people think certification or licensure surveys are something to fear.  At the Arizona Department of Health Services (ADHS) and particularly at ASH we take a different approach.  Surveys are an opportunity.  They are part of the quality improvement process that health care facilities employ to make sure patients receive high quality care.  

A few weeks ago we had a return visit from CMS surveyors to verify whether we executed our Plan of Correction.   The entire team at ASH did a great job during the inspection- ensuring that the surveyors had everything that they needed to meet their objectives.  The required documentation was easy to find, and the surveyors got to see how well our team works together.  Today we received good news from CMS.  They’ve concluded that we’re satisfying their requirements, and that the Arizona State Hospital is in good standing, including our Deemed Status as a result of our Joint Commission Certification.  Congratulations Team ASH. 

Having external entities such as CMS and the Joint Commission (JC) review your organization creates an exceptional opportunity to get a fresh set of eyes on what a facility is providing for services.  If you think about it in the quality realm, the survey is an evaluation using evidence based practices.  Survey and accreditation standards are built to determine whether programs are delivering services in accordance with the accepted “Standards of Care” that have been developed from years of surveys, experience, research and best practice from regulators, clinicians, academics, legal analysis and patient experience.  Why would a program not want to have an opportunity to be evaluated according to these standards? 

So while some people look at surveys and their results as a negative reflection on the program we need to reframe that look from the lens of quality.  We want quality services and outcomes for patients.  Learning from both internal and external quality processes helps organizations meet those goals.  Continuous quality improvement only happens when you continually evaluate the services through the quality lens.  The team at ASH and ADHS is proud of the work that staff at every level are doing to meet the needs of some of Arizona’s most vulnerable citizens and fulfill our requirement of delivering high quality care. 

BTW: You can read more about some of our initiatives to improve the quality of care at the State Hospital here and here.