CSI Duluth DON Observational Survey Experience Communication Points

  • The DON Observational Survey Experience processes have been completed.
  • The DON Observational Survey Experience processes have been very beneficial. We needed to finish this process in order to have a broad base of information to share without the ability risk of to identifying a specific facility. At the conclusion of all four processes, we will pull together a more comprehensive report. Information presented will be general in nature and not facility specific.
  • If the facility is in the “survey window” and the survey team is due to come into the facility, be prepared.
  • Have the current State Operations Manual (SOM) and regulations available in the facility and educate staff on where it is and how to use it.
  • The survey team asks a lot of questions because they are trying to tie multiple pieces of information together. It’s important the survey team explain to facility staff why they are repeating or rephrasing questions they may have already asked.
  • Issues at a facility are identified through the survey process, regardless of who is on the survey. Issues are brought to the team by individual surveyors and the team makes the determination if a deficiency should be issued.
  • Immediate jeopardies are determined by the entire team – everyone has a voice in making the determination based on a review of Appendix Q. If the team decides it is potentially an IJ, the unit supervisor is called, and eventually the St. Paul office is called. It is not an individual’s decision.
  • During team meetings, including decision-making, there is a lot of team discussion and healthy debate on issues.
  • During tag review, the team discusses concerns to ensure that decisions are consistent with previous deficiencies cited and any updates received.
  • If something wasn’t identified to the facility as an issue during previous surveys, that doesn’t mean it wasn’t a deficient practice. The team may not have been led to do an investigation in previous surveys, but was led to investigate the concern in the current survey.
  • If there are concerns about the survey team, the concerns need to be brought forward to the team leader or supervisor. For best resolution, it helps to have specifics about the concerns.
  • Minnesota Department of Health supervisors are on site to evaluate the team and work with the team, not necessarily because there are problems with the facility. It is part of the MDH quality assurance and quality improvement work.
  • Communication is a two way street.
  • It continues to be crucial to identify and develop improved communication and educational opportunities. Through this process, we have identified areas in which all stakeholders could benefit.
  • Network. Use the provider organizations, peers, consultants, etc. available to you. Talk and share information, ask questions. As questions arrive, talk with the MDH unit supervisor.
  • The need for shared practices continues to be recognized for all stakeholders. A mechanism needs to be identified, developed, and implemented to share those practices.
Updated Tuesday, November 16, 2010 at 12:31PM