Hospital System Weathers Multiple Disease-specific Care Surveys

Matt Phillion, for HealthLeaders Media , September 2, 2009

Though Disease-specific care (DSC) certification surveys provide a little bit more notice for hospitals than The Joint Commission's triennials, a six-hospital system with multiple DSC programs may need to handle surveys uncomfortably close together.

For Main Line Health, a six-hospital system outside of Bryn Mawr, PA, this meant four surveys in three hospitals between February 2009 and August 2009. With the right prep work, however, four surveys in a six-month period did not mean panicking, says Mary McKay, RN, MS, CPHQ, system director of regulatory affairs and nursing quality. The system weathered a ventricular assisted device (VAD) destination therapy program, primary stroke center certification, and two knee and hip programs successfully in a matter of weeks.

The prep work is similar to The Joint Commission's triennial survey, says McKay.

"It's very similar—you do your annual Periodic Performance Review (PPR) and take your action plan from that," says McKay.


Surveyors, McKay found, were very interested in education during DSC surveys.

"One quote all of the surveyors used: What makes you different?" she says. "What sets you apart from the hospital down the street? That's a message we hadn't seen in print before, and it really drove the message home, to refine the program and give it a unique look."

The education component is more prescriptive in some programs than others.

"With stroke, there's a big education requirement," says McKay. "Each staff was asked, whether they were nursing or therapy or anyone else, what additional training you had in this area. And whether you're looking at stroke or knee and hip, or VAD, that education sets you apart."

Staff education also reflects on the hospital as a whole.

"From the surveyor's point of view, they also want to know that having this additional education shows leadership's commitment to the program. Education is part of the organization's goals," says McKay.

For their knee and hip certification program, the healthcare organization had developed an individual care plan for patient education.

"Folks come in with a pre-op visit, and that education follows them through their hospital stay," says McKay. "Post-discharge there's a chance to participate in further education."

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