DNV survey highlights our system approach, and our flexibility

The Regulatory Affairs team used a mobile unit, complete with an iPad and laptop, to connect surveyors with staff members as they walked through the hospital.

This spring, CoxHealth was due for our checkup DNV survey, and we were ready for a traditional onsite visit.

Then, COVID-19 made everything traditional obsolete.

DNV’s teams, who evaluate health systems and assess their regulatory compliance, asked the question so many are asking: How can we do our work remotely?

They asked for volunteer health systems to try something different. DNV’s new approach would use technology to examine health care processes and compliance, a task that had always been done in person.

CoxHealth stepped up. Sarah Barkley, accreditation manager in Regulatory Affairs, says we were ready and confident in our preparation.

If we got the technical abilities in place, we could be among the first systems surveyed using videoconferencing technology.

We would need a lot of flexibility and innovation. Making the survey happen required the teamwork CoxHealth is famous for, and it ultimately revealed the strength of our systemwide processes.

“I was so proud of how well our team adapted to the switch in plans,” Barkley says. “It was different than were used to, but our team embraced it and did an amazing job with it.

“The teamwork that happened to have this accomplished with such positive attitudes was a wonderful thing to see.”

Going digital and remote

Barkley says the team quickly partnered with Si3 to make a teleconferenced survey possible.

They began with a mobile telehealth cart, which offered high quality video and audio, as well as a computer screen and hookups for a laptop.

Those carts connected with DNV through Microsoft Teams, the same platform Si3 had used to expand clinic access to telemedicine.

It was, in Barkley’s words, “a very non-traditional approach.”

The team usually uses scribes traveling with surveyors in person. Now, they had a staff member moving the cart, while another took notes and facilitated interactions with staff.

Facilitators used iPads to help surveyors look into ceilings and hard-to-reach spots.

Soon, they attached the iPad to the cart. This allowed surveyors to see as they were walking, and speak with staff members, just as they would have done in person.

“It was a little like that ‘Big Bang Theory’ episode when Sheldon tried to be a robot,” Barkley says with a laugh. “It turned out to be a wonderful setup. It let the surveyor feel like they were there with us, and it let staff interact. It was a great working relationship.”

The process required a lot of adjustment, and it soon revealed advantages that are likely to extend beyond COVID-19.

For example:

Barkley’s team provided documentation digitally for the first time. Instead of printed binders for all surveyors, the team shared documents on Microsoft OneDrive.

“This allowed us to provide all the required paperwork without all the paper,” she says. “The surveyors could reference them easily and they loved it.”

Another advantage? A single survey team was able to see all of our hospitals. When they visit in person, coordinating travel schedules usually means different surveyors visit each campus.

This time, the same surveyors saw the entire system, from the comfort of their homes and offices.

“We had such an amazing rapport with them since we had the same surveyors for whole system,” Barkley says. “They were light and jovial -- they were more ‘at home’ literally being at home.”

The surveyors agreed it was a success. They plan to share CoxHealth’s approach with the DNV advisory board.

“They told us, ‘you all have set the bar high on the remote process,’” Barkley says.

How did we do?

After several days of observation, DNV produced their reports on how we are currently doing. Overall, the news is great.

Surveyors recognized CoxHealth as an extremely high-functioning organization. They noted our success with standardized, systemwide processes and our integration across all of our hospitals.

Almost everything DNV examined had a COVID-19 angle.

“They were impressed with our COVID-19 planning and our incident command structure,” Barkley says.

In addition, they noted the strength of CoxHealth’s leadership.

They appreciated how CoxHealth has continued to provide great care, while demonstrating a strong commitment to employees through preventing layoffs.

“They saw our staff reassignments as especially creative and innovative,” Barkley says.

Surveyors also recognized our dedication to internal and external communication.

“They loved that were active in making sure the community is aware of what is going on and how they can be safe,” Barkley says. “We shared the intranet site and all of its updates available to staff. They appreciated the transparency and they were impressed with the level of communications in an organization our size.”

Other areas of success the surveyors noted:

• Our efforts around PPE preparedness
• The CoxHealthSAFE app
• The rapid deployment of the new COVID-19 unit

Where we’re headed next

Of course, surveys are designed to help us be our best and part of that means finding opportunities for improvement, or OFIs in DNV lingo.

Most of what surveyors noted on this checkup visit were things we were already aware of: small details we are constantly working to improve.

There are always chances to make our processes more standardized, for example. If you see an opportunity at one location, there’s a good chance it can be improved across the system.

One example Barkley notes: operating room fire safety.

DNV looks closely at how we assess fire risk, how we do fire drills and how we deploy staff education. Ideally, we will have the same policy and training everywhere.

Barton County had a different standard for assessing fire risk. Other areas lacked documentation that providers had participated in OR fire drills. Surveyors identified those differences as an opportunity.

“It’s about consistency and standardization with all of our processes,” Barkley says.

That extends from standardized safety procedures to making sure areas like labs have the same processes across the system.

“We want to make processes that have zero extra steps. Every step should be necessary and we should work to perfect each step for the best outcomes,” Barkley says.

Next year will be CoxHealth’s full reaccreditation survey. The Regulatory Affairs team hopes to use the technology proven this year to give more of us a window into the survey process.

“Microsoft Teams allows more people to participate,” Barkley says. “Even if we do the visit in person, we could hook up a Teams meeting at the opening and closing session and share it.

“We want people to engage, have a feel for the process and understand the reasoning behind it. We do all of this for safer patient care, to keep us safe and to keep our patients safe.”

By the numbers

It’s all about improving quality and safety, and Barkley is quick to point out that the regulatory team – and our DNV surveyors – are collaborators in making those improvements.

“DNV is collaborative and they are there to drive us to be better. They’re a partner who can give us ideas about improving ourselves.”

This year, we had a record low number of what DNV calls “non-conformities” – issues where there is evidence that an accreditation standard was not addressed, not implemented or not effective.

Cox Monett and Cox Medical Center Branson each had zero non-conformities. Springfield and Barton County each had two.

In the graph above, you can see the trend in DNV “findings.”

Each finding is a piece of evidence that can support a non-conformity (a non-conformity can be supported by more than one finding, so there are typically more findings than non-conformities).

Years in blue above are the initial accreditation (2015) and reaccreditation (2018) years and are comparable. Years in yellow are the annual check-up surveys.