The on-site survey is often seen as the final hurdle before accreditation. Healthcare leaders on the path to accreditation put considerable effort into making sure that their facilities are survey-ready and in compliance with QUAD A standards, but there’s one more step that’s just as important as the survey itself.
The Plan of Correction (PoC) is the critical final step between the survey and receiving accreditation. The PoC is a roadmap that facilities must put together themselves, indicating how they will address any deficiencies identified in the survey.
Putting together an effective Plan of Correction requires intention and a commitment to prioritizing patient safety. Here we’ll outline the path from survey to PoC, the key elements of a successful PoC, and how your PoC can lay the groundwork for continuous improvement.
Survey Outcome: Determining Compliance and Identifying Deficiencies
After your survey is complete, you’ll receive a determination of compliance from the QUAD A Central Office. The determination summarizes how well your facility complied with QUAD A Standards during the survey. Each standard is marked as “Compliant” or “Deficient,” with “Not Applicable” used for non-Medicare facilities when appropriate.
If the surveyor identified deficiencies with any standards, the report will point out the manner (seriousness) and degree (extent) of noncompliance. Each deficiency will be identified as one of the following:
-
Standard-level Deficiency — Indicates noncompliance with one or more of the standards that make up each condition of certification.
-
Survey Outcome: To achieve accreditation, the facility must submit a Plan of Correction that describes how each deficiency will be mitigated.
-
-
Condition-level Deficiency — For Medicare-participating facilities only. Indicates substantial noncompliance with Medicare Conditions for Participation.
-
Survey Outcome: To achieve accreditation, the facility must first submit a Plan of Correction that describes how each deficiency will be mitigated. QUAD A will then conduct another on-site revisit to assess the correction of deficiencies.
-
-
Immediate Jeopardy — The highest level of deficiency. Indicates that the degree and manner of the noncompliance has caused or is likely to cause significant injury, harm, or death to a patient.
-
Survey Outcome: Accreditation will not continue unless the immediate jeopardy is removed.
-
It’s natural to feel discouraged when deficiencies within your facility are pointed out. Remember: the ultimate goal is patient safety. Putting together a Plan of Correction is a valuable opportunity for your facility to optimize processes, enhance compliance, and improve patient outcomes.
Four Keys to a Well-Executed Plan of Correction: What, Who, When, How
Once you’ve received your report detailing deficiencies, your next step is to build a written Plan of Correction. Your Plan of Correction tells QUAD A how you intend to address each deficiency and comply with the relevant QUAD A Standards.
A well-executed Plan of Correction will cover four criteria for each identified deficiency: your plan for corrective actions, who is responsible for those actions, when they will be implemented, and how they will be evaluated in the long run.
#1: What will be done to correct the issue?
The first step of a well-executed Plan of Correction is to plainly state what you will do to address the identified deficiency.
Be as specific as possible. If one of the deficiencies identified during your survey was improper drug storage, it’s not enough to say, “Drugs will be stored appropriately from now on.”
Instead, your Plan of Correction should detail:
-
The specific location where you intend to store drugs moving forward
-
The conditions under which those drugs will be stored
-
Who will have access to drugs and under what circumstances?
-
What training will be done to put the plan into effect?
-
What staff members (by title) will receive this training?
-
Etc.
#2: Who is responsible for implementing the corrective action?
Outlining a corrective plan is a great first step, but accountability ensures that the idea gets put into action.
Every Plan of Correction must include the title (not the name) of the person responsible for implementing the corrective action.
#3: When will the action be completed?
You’ve outlined the corrective action and identified who will implement the plan—now it’s time to put it on the calendar. Your Plan of Correction must list a completion date for each deficiency.
For less complex deficiencies, you may be able to complete the corrective action before submitting your Plan of Correction. In this case, list the date that the correction was completed. For example, the date that a new process was implemented to maintain facility cleanliness.
More complicated deficiencies may require more time and planning to correct. In this case, it’s okay to list a future date when the correction will be made. For example, the date that all nursing staff will complete a half-day training session.
You will be required to submit documentation proving that the corrective action was taken on the listed correction date. For example, a signed and dated document showing when a policy was approved by the Medical Director.
#4: How will the effectiveness of the action be evaluated?
Your Plan of Correction is in motion, but how will you ensure that it yields the desired outcomes? Measuring the success of your corrective actions is the final key to a well-executed PoC, demonstrating whether your plan has had its intended effect, not just in the short term, but also whether it lays the foundation for long-term improvement.
These two tips can form the backbone of your evaluation:
-
Identify metrics for success
-
What metrics can you track that will demonstrate your commitment to ongoing improvement?
-
Will these metrics be monitored through a score sheet, a review form, a dashboard, etc.?
-
-
Establish regular monitoring
-
Who specifically will monitor the metrics for success?
-
How often will that individual monitor those metrics?
-
For how long will those metrics be monitored?
-
How will this ongoing monitoring be documented?
-
What will you do to ensure that those metrics are met within the specified timeline?
-
Plan of Correction Support from QUAD A
The path to accreditation continues when you submit Evidence of Correction (EOC) showing that the identified deficiencies are now in full compliance with the corresponding standards. If you need support building your Plan of Correction, QUAD A is here to help.
Learn more about the accreditation process and take the first step toward accreditation today: https://www.quada.org/prospective-facilities
