NCCHC Breaks Barriers to Conduct the First Virtual Accreditation Survey

In mid-March, as COVID-19 swept the news and the nation, NCCHC leaders initiated a plan to protect the health and safety of surveyors, correctional facility employees, and the incarcerated, while continuing the vital mission of accreditation. “Now, more than ever, we want to be able to provide feedback to facilities on the quality of their health care and offer them as much assistance and mentoring as we can,” says Jim Martin, MPSA, CCHP, NCCHC vice president of program development.

In a recent call with other accrediting organizations, NCCHC was one of the first to have conducted or planned a virtual survey. This pioneering effort required innovation, cooperation, and the dedication to patient care that characterizes successfully accredited facilities.

NCCHC used a HIPAA-compliant video platform to ensure confidentiality. This would resolve questions about sharing sensitive health information via the internet. The next step was finding a facility that would be comfortable as a pilot site and had supportive leadership and electronic health records. A large jail scheduled for a reaccreditation survey in early May seemed to be a good option. (It is not named to preserve confidentiality.)

Martin and the NCCHC accreditation team quickly developed new protocols to make sure the rigor of the survey was not compromised:

Pre-review of patient records: The facility sent required electronic documentation in advance to the lead surveyor. Before the survey went live on May 11-12, the survey team had already reviewed and assessed on many standards. Martin says, “There was a real benefit because the survey team had a much better idea what they were going to see and it greatly reduced the burden on the health care staff during the survey. This was especially important because we didn’t know if they would be dealing with COVID-19 emergencies. Usually we spend quite a bit of time reviewing this documentation on-site. We were able to reduce a planned survey with four people over three days to two people over two days.”

Virtual conferencing: While the surveyors anticipated that meetings with the health care team would easily be accomplished, NCCHC accreditation requires interviews with randomly selected patients. Custody and health care worked together to allow the patients to have private discussions with surveyors over secured phones or tablets.

Pharmacy: Health care staff used a phone to walk through the pharmacy area. Surveyors requested to see randomly selected medications on the shelf and in the refrigerator and the staff was able to get closeups of specific bottles.

Inspection of specific areas: Using phones and laptops, facility staff gave live “tours” of living areas, receiving, screening, and patient care areas.

For other facilities facing accreditation or reaccreditation this year, NCCHC Vice President of Accreditation Amy Panagopoulos, MBA, BSN, RN, has identified key factors for success:

• Electronic health records: EHR greatly facilitates virtual surveys and makes the process seamless.
• Leadership support: Since the survey depends on mobile devices and the internet, custody may need to re-evaluate some restrictions or protocols.
• Connectivity throughout the facility: Moving through various areas with a live video feed is extremely helpful. Martin notes that it could be accomplished with digital photos, saying, “There has to be a basic level of trust between NCCHC and the facilities.”

Panagopoulos sees tremendous benefits in accomplishing a virtual survey, even after COVID-19 restrictions are relaxed. “While we don’t foresee moving completely to virtual surveying, we want to continue the pre-visit document review to streamline the on-site visits. Plus, we can still conduct a survey if there’s a snow storm or other emergency with our traveling surveyor team.”

The staff at the jail rated the survey experience 10/10. The director of behavior health noted, “It was very exciting to take part in the very first virtual survey for our company, this facility, and NCCHC. I am glad I got to be a part of it and I believe it went very smoothly.”

NCCHC thanks the leaders and staff and congratulates them for their flexibility, creativity, and above all, concern for the health and safety of all involved.

For more information, contact Panagopoulos at [email protected].