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Louisiana Association for Healthcare Quality

Survey Readiness Blog

  • 9 Sep 2020 9:32 PM | Anonymous member (Administrator)

    It was late Q4 of 2019 and time to begin the wrap up of your lessons learned for the year and begin your strategic gap analysis to put you thoughtfully on the right track for an effective 2020 strategic plan development and deployment. January rolls around and you were feeling confident that your framework, cycles of improvement and strategic gap analysis for 2019 is fully vetted and alignment achieved among your operations team for a continued improvement cycle in 2020. Then, no quicker than deploying your plan, COVID-19 came to visit. Well, you know what they say about “best-laid plans.”

    Immediately, you were faced with new priorities, rightfully so, and you could do one of two things. Throw your hands up and surrender to the thought that quality improvement cannot happen concurrently with a pandemic OR throw your hands in and get busy revisiting, redesigning and adapting to your new challenges, new goals and “new normal”.

    I bet most of you threw your hands in! Now more than ever, our organizations needed to gain new efficiencies under a locked down environment; needed improved safety measures to ensure our stakeholders had confidence in their work, recovery and living environments; needed a sense of stability to avoid stagnation; needed to mitigate operational failures and, well, frankly avoid loss of life.

    Whether you were successful to throw your hands in or you found yourself, for whatever reason (no operationalized support for quality improvement or resources drained) throwing your hands up, you likely did or needed to do some of the following:

    Prioritization or Re-prioritization:

    First, determining what MUST be established NOW to ensure the safety and health our stakeholders-

    • Deploy an emergency response or you will stay in a reactive and stressful cycle which is NOT conducive to being strategic.
    • Gather your team. Hopefully, you have spent time pre-pandemic learning your team members’ strengths and how they complement yourself and a quality program’s success.
    • Define your trusted resources for guidance and best practice development.
    • Give yourself a realistic time frame to devise and/or deploy an emergency response including an opportunity to acutely conduct a gap analysis and cycle of improvement of what was deployed.
    • Do not reinvent the wheel. Be willing to see what your network or member organizations may have already developed or use other emergency plans that can be adaptable: examples like hurricane response, disaster response plans and so on.
    • Emergency response plans are hypothetical at best and based on what we hope will happen so give yourself some grace if it does not go perfectly as planned BUT be committed to quick resolutions and improvements.

    Second, what is our “new normal”-

    • You could say “virtual is the new black”.  With quarantine, stay at home and regulatory restrictions on healthcare settings, we must still be “visible”.
    • Consider your multiple virtual visitation needs:
    • o   Medical profession visits may require a telemedicine/telehealth platform.
    • o  Family/resident-patient visits should be explored via the preferred virtual media platform they desire.
    • §  This may mean needing to secure iPads, cellphones and/or adapting telehealth equipment to be the medium for these virtual visits.
    • Design a virtual facility support model to ensure operations moves forward.
    • §  Consider virtual mock surveys conducted via ZOOM, Microsoft TEAMS, FaceTime.
    • §  Consider virtual meetings at the facility level and regional level to ensure safe social distancing and non-essential visitation practices.
    • §  Consider converting on-site or regional required trainings, competencies where able to virtual platforms.

    Gap Analysis:

    At this point, you should have secured a reasonable amount of stability through an effective emergency response. Next you should conduct a gap analysis: a formal study of what your operations is currently doing, where it wants to go, and how you close the gap between the two. It compares desired and actual outcomes and pinpoints opportunities for improvement.

    • It is important to start with what our gaps are between what we wanted to happen in 2020 vs. what can happen in 2020 under a pandemic scenario.
    • As you analyze your original 2020 strategic plan you should consider-
    • o   What goals are still applicable/achievable if we simply get more granular? If they are, go ahead and get more granular and simplify to match the amount of time left in 2020.
    • o   How does our new normal affect our abilities to execute our 2020 strategic plan? Is it adaptable/achievable under our new normal? If yes, adapt and move forward.
    • o   Do your goals need a rebase? Typically, we may use year over year for measuring progress. Your updated goals may now need a first half of 2020 rebase and an adjusted improvement standard for the remaining six months of the year.
    • o   Do you need to add or completely replace your goals? Has the “work from home” or re-prioritization created new opportunities for efficiencies or a refocus?  EX: Is your electronic medical record platform fully deployed? Used to its fullest capacity? Under the COVID-19 environment, does gaining these full deployments improve our resident/patient assessment and thus our outcomes under the pandemic?
    • If working under a Baldrige framework,
    • §  make sure you address each of the strategic areas for goal changes or updates
    • §  engage your committee team leaders/members as time and resources allow
    • §  and guide them through the process of gap analysis and goal re-writing.

    Cycles of Improvement:

    Alright, now you are feeling accomplished again. Just maybe 2020 is salvageable despite being our industry’s most challenging in our lifetime. But wait. There is a little more to do. Just as you would have done for your full original 2020 strategic plan, you need to agree to intermittent time frames to measure our newly re-deployed plans and progress towards those new goals.

    • Consider creating intervals for re-evaluation that are monthly vs. quarterly.
    • Consider meeting virtually more frequently for all strategic committees or quality team members to share their focus area progress or barriers-there may be solutions through this sharing process.
    • Make timely changes from lessons learned and cycles of improvement.

    Progress is progress:

    In a time that seems like a bad dream, over regulated and under-appreciated, you set the tone and commitment for quality improvement.

    • Celebrate your early wins! Use the dashboards of your EHR, group apps or texts, social media, or other communication platforms to reach as many stakeholders as possible. You need cheerleaders and we need to counter the abundance of pandemic negativity.
    • Adjust those goals that seem too over reaching or daunting once you get into them. Its ok to change the play book if the integrity of the strategic plan is maintained.
    • Stick to it! If it is not important to you, it will become less important to them.

    Whether you are responsible for quality improvement at a department level or enterprise level, exploring these steps on either scale will produce success with some if not all your re-imagined 2020 strategic plan.

    If you have navigated the pandemic and your quality strategy concurrently-nice job! If you are stuck-It is not too late! Hands in!


    Tara Roberts PT, QCP

    2020-21 LAQH Treasurer

    VP of Quality and Rehab/Wound Care Services

    Nexion Health Management, Inc.

  • 10 Mar 2019 11:17 AM | Anonymous member (Administrator)

    What are lessons learned from Joint Commission or DHH/CMS surveys?

  • 10 Mar 2019 11:16 AM | Anonymous member (Administrator)

    What are hot topics or lessons learned from NCC (joint commission survey) or DHH/CMS surveys?

  • 10 Mar 2019 10:38 AM | Anonymous member (Administrator)
    Post lessons learned during recent surveys.  What surprises or known issues where uncovered?

About the association

Since 1976, the Louisiana Association for Healthcare Quality has been a guidepost for healthcare quality professionals. We were founded in 1976, later incorporated in 1982, and officially named the Louisiana Association for Healthcare Quality in 1995. LAHQ enjoys a diverse membership that includes professionals from many quality-related disciplines such as utilization, risk, case management, patient safety and infection control.




PO Box 1651 E. 70th Street #304

Shreveport, LA 71105


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