May 6, 2024

Message From the CEO

CHCS is in their Kansas Department of Health and Environment (KDHE) state survey window. As you may remember last year, this time, CHCS placed a series of Survey Readiness Newsletters in the e-Connection. It’s time to review these important steps to ensure we are ready for any upcoming state surveys. This survey will be of hospital services only. Our success will require the cooperation and support of the entire staff and depends also on everyone’s familiarity with regulatory requirements in their particular area. We will send out regular communications to help each of us prepare to demonstrate our competence and our commitment to excellence in all we do.

KDHE is an organization of Kansas that measures hospital performance. They are required to survey hospitals every 5 years. Achieving accreditation means that the hospital has met or exceeds state and federal regulatory standards. CHCS last state survey was in the spring of 2017.

Accreditation is a seal of approval. Without accreditation our hospital would lose its professional standing and community image. It would also affect financial reimbursement for services provided for patients because we would not be able to bill and, most important, would not reflect our dedication to providing top-quality patient care as we strive to enrich the health and lives of the people we serve. In preparation for the unannounced visit, every hospital department will be reviewing policies to assure they are up to date, physical environments will be evaluated for cleanliness and safety, and education will be provided to assure that you have the knowledge you need to be successful during the survey.

Todd Willert

Chief Executive Officer

Building Relationships and Communication

Though a successful survey depends on a number of elements, a major key to success is the ability of our associates to interact with the survey team and demonstrate the exemplary care they provide. Our goal is that the information contained in this, and future Newsletters will prove useful in preparing for this survey interaction. Please remember that every associate plays an important role in the organization and has an impact on the care provided to our patients.

Survey—Q & A’s

How will we be surveyed?

A team of at least two surveyors will be onsite for four days. They will review our documents and policies, so they understand our processes. They will then move throughout the building observing practices, documentation and the environment, as well as interviewing staff and patients. Surveyors will ask questions about the care each patient received, and the steps taken to ensure that it was safe, of high quality and follows our policies.

How will I know KDHE is conducting an unannounced survey?

Upon their arrival, communication will be sent to the managers and directors. Your manager will keep you informed of survey progress.

What is my role in the survey?

You and every hospital employee at every level are very much responsible for upholding the hospital’s mission and providing excellent patient care. Surveyors will speak with you about your individual job.

Start by checking and making sure all your licensures are up to date. Then check in PowerDMS and be sure you have reviewed all policies and procedures assigned to you for review.

Who is in charge of survey preparation in my area?

Your department director and manager are responsible for survey readiness of your area. However, YOU are also responsible for your own participation and preparedness.

Who sees the results of our survey?

Anyone who wants to. The results are made public and available on the Internet. Our competitors, payers, referring physicians and—most importantly—our patients and their families will be able to read the details of our performance.

What should I do if a surveyor

asks me a question?

· Listen and stay calm.

· Think carefully before answering a question.

· Only answer the question asked by the surveyor. You do not need to elaborate. Keep your answers focused and specific to the question. It is okay to ask your manager to be there with you.

· If you don’t understand a question, ask for clarification.

· If you do not know an answer, say so, and tell the surveyor where or to whom you would go for the answer. You may use any resources available to you, such as policies, department resources or your manager. And remember to use your resources (i.e. PowerDMS, MSDS, Department resources at the computer)

· Always be honest. Falsification or misrepresentation can cause the organization to lose its accreditation.

· NEVER argue with the surveyor. Be professional and use appropriate language and behaviors.

· Whenever possible, mention our practices and procedures that support your answers.

· Show off your successes and the things you know and do well.

· Exhibit pride in your department.

· Show enthusiasm and interest!

--these can be found posted at the employee entrance to CHCS, in waiting rooms, on the “about” page of our website chcsks.org

"Enrich the Health and Lives of the People We Serve"

We Will Be the trusted resource for quality, innovative, personalized care,

We Will Be the integrated healthcare system of choice allocating resources to be responsive to the unique characteristics of the communities we serve, and

We Will Be an outstanding environment for our associates.

True to our heritage, we hold the following values.

· Integrity.

· Excellence.

· Respect.

· Compassion.

· Commitment.

· Innovation.

· Loyalty.

· Collegiality.

· Kindness.

· Citizenship.

· Accountability.

Questions? Send them to mandathompson@chcsks.org

May 6, 2024﻿

Message From the CEO

Building Relationships and Communication

Survey—Q & A’s

May 6, 2024