LUSK - In an unusual move, the Wyoming Department of Health recently completed not one, but two performance surveys of the Niobrara Community Hospital.
The first, a routine examination of NCH compliance with state and federal operations and care standards, took place in October. The second, which saw an examination team back at NCH virtually on the heels of the first, came in response to allegations of staff shortages and inadequate patient care being provided to Extended Care Facility residents made by former staff members.
The hospital passed both with flying colors, with examiners finding nothing untoward in either hospital operations or care.
“These surveys are an opportunity for the facility to learn and improve,” Chief Operations Officer Kody Nelson said. “State findings are just helpful to get better.”
NCH underwent its regular survey and inspection from the Department of Health in October. These surveys are standard practice and occur once every three to four years.
The state checks everything about hospital operations and care for compliance with state and federal statutes on critical access hospitals. They are not scheduled and facilities do not know about them until the state staff show up at the facility.
The state surveyors closely examine everything from patient care procedures to orientation to physical credentialing. The findings in this survey were minimal, with inspectors telling hospital administration they were impressed with the facility.
These findings are available for public review and are mandated to be posted where the public has access.
Shortly after the standard survey, the state received a complaint the hospital was understaffed and not providing adequate patient care or activities for ECF residents because of the staffing schedule.
In the case of a complaint alleging to the department of health ombudsman, the state can choose to initiate a complaint investigation. A complaint investigation differs from a regular survey because the survey team is usually smaller and inspectors focus on the specific area or areas related to the complaint.
In the event the team observes something in the course of the complaint-specific survey outside of that department or process, they have the right to expand the survey up to a full-facility survey.
The survey team was at NCH for six hours. They observed and audited nursing staff schedules, work routines and processes, reporting they found nothing wrong. A zero finding survey is almost unheard of. Surveyors can almost always find ways that a facility can or should improve something within any department, policy or process.
During the exit interview, the surveyors stated that not only were there no findings, but they were so impressed with the quality improvement program referred to by Nelson as “A Standard of Excellence” that they requested a copy of the program to take back with them to use as resources and review for recommendations.
Nelson said the results of the complaint survey highlights how hard NCH nursing leadership has been working with the staff to improve everything in the hospital from patient care to documentation. Every staff member is working to the peak of their license, not beyond. In the six weeks between the full survey and the complaint survey, the hospital had already made improvements that were noted by the state.
The complaints had originated from individuals who disagreed with the direction administrators are taking the hospital. Nelson states that he never minds when the state comes in since it is always an opportunity for the hospital and staff to learn.
“Where there is improvement and expectation changes, there will always be conflict and dissenting opinion,” Nelson said. “It is a difficult process and definitely changes the perspective some people have on whether we are a good fit for them as a place of employment.”
Nelson credits Director of Nursing Melony Woodall and Chief Nursing Officer Amber Ondriezek with the improvements in the hospital. Woodall says that all her staff are committed to improvement and that Merri Keller, CNA and Misty Goodwin, EDTech were instrumental in a successful complaint survey.
Nelson also said the hospital is committed to consistently improving patient care. Even though there were no findings at this survey the hospital will not simply stay at the level they are at, but will continue to strive for higher standards in every department, he said.