Lending a hand with surveyor training: how one facility hosted a CMS training video aimed at improving state surveyor performance.

What four-word sentence can produce a knot in the stomach of anyone who works in a nursing home?

"The surveyors are coming."

It doesn't matter if all staff--from administration to frontline workers--have all the faith and pride they can muster in their facility; they know that when it comes to deficiencies (or lack thereof), sometimes it's as simple as Surveyor A citing something that Surveyor B would let slide.

"It's all in the interpretation," says David Abraham, administrator of Sentara Nursing Center-Norfolk (Virginia). And so it was in the name of consistency that Abraham was more than happy to volunteer a wing at his facility for the production of a training video, underwritten by the Centers for Medicare & Medicaid Services (CMS), to instruct federal and state surveyors.

The Goals

The Virginia Department of Health had put out an electronic call for an administrator to offer his or her facility as a setting for the video. Abraham saw this as an opportunity he couldn't pass up: "I thought it would be a good learning experience for the staff. I figured they could see what the surveyors are looking for when they come in, kind of up front and personal." But just as important, says Abraham, is that any deficiency, at any level of scope or severity, can differ in interpretation not only from region to region, but from state to state; surveyor consistency has been a problem. It was for the "greater good," therefore, that Abraham heeded the call.

Realizing that a combination of high turnover of surveyor staff and nonstandardized training accounts for at least some of the inconsistency, CMS saw the need for a training video to use in its Basic Long Term Care Course for surveyors. Remtech Services, Inc., a video production company headquartered less than an hour from Sentara-Norfolk, was hired to produce the video. With most of the actors living close by, the production proved to be cost-efficient for CMS, saving the government dollars in terms of travel and lodging. And Sentara-Norfolk, as host facility, realized its own advantages.

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The Production, the Results

The video's story line is a surveyor's tour of a "fictitious" facility, but it was the job of Catherine Morris, MS, to set up the scenarios, including those in the facility's very real kitchen. Morris is a dietitian and former assistant commissioner of health for the Division of Long Term Care Systems in New Jersey. "We actually created some sanitation problems in the kitchen for the sake of the filming," she recalls. "One of the things we showed, for example, was staff members putting away big serving trays in soiled condition (and we used oatmeal for the soiling). We also showed improper storage of dry food, as well. The actual kitchen staff was very gracious about this, because they had to continually clean up after us.

"The kitchen was one of the harder parts of the video to shoot," Morris continues, "because it was always in operation. There's very little downtime in a nursing home kitchen because it serves three meals a day, plus snacks, plus staff meals. This was all the more reason to appreciate the kitchen staff's graciousness."

Morris points out that some of the scenes were included in the video purposely to generate discussion: "For example, there was a simulation of leftover food sitting out on a stove surface, and the stove hadn't been turned on, and the 'surveyor' noted that. But just seeing it as a onetime shot doesn't mean it's a deficiency. You'd want to follow up on it--maybe take the temperature of the food, or see how long it was left at room temperature before the staff refrigerated it. We were trying to point out that you have to investigate these things further."

The camera's presence had some therapeutic value for residents, as well, says Morris: "I think it was a good experience for the nursing home because the residents loved the excitement. There were even some who signed releases so they could be in the background shots."

Jane McNally, RN, teaches the five-day Basic Long Term Care Course during which the video is shown. As a licensed nursing home administrator who also conducts surveys, she helped develop the course training manual and was deemed the perfect choice to act as one of the project's two on-site technical advisers (Morris being the other). Like Sentara's Abraham, McNally calls the video "a real learning experience. We were there ten hours a day, eight days in a row, through the weekend. The technical advisers had to be there for every scene so we could prompt the actors and actresses. I would also check to make sure a catheter was placed properly, for instance, or I'd prompt the prop person on what the urine should look like in a particular scene."

McNally also instructed the actors who played residents, helping them to grasp the behaviors that each malady might exhibit. Her lessons ran the gamut from a Parkinson's disease tremor to the physicality of a COPD patient. "One man who was supposed to have emphysema was as thin as a rail, so I had to use a pillow to make him have that barrel chest," she remembers.

In fact, McNally was as impressed with the makeup artist as she was with the actors: "She was so terrific. She's done makeup for Tom Cruise, so you know she was good. But what also struck me was how professional the actors were. Some scenes took up to eight takes before the producer was satisfied. Yet the actors and actresses never became impatient. They remembered their lines and looked as fresh on the seventh take as they did on the first. I remember one woman needed to have her eye tear. There were so many takes of this, and they put so much product in her eye to make it tear that by the end of the sequence her eye was very irritated, but it didn't deter her performance."

Underscoring the purpose of a training video, McNally notes that "seeing and hearing concrete examples are more effective than just reading a manual." Every time she has shown the video to her students, she has gotten rave reviews. "They tell me how great it is and how they feel as though they were there. We also portrayed some resident and staff interview techniques, which has been equally effective. Before, we'd just talk about interviewing, but in the video we show both poor techniques and good techniques, and the students have found it to be a much better learning tool in this respect."

One of the featured discussions in the video deals with CMS's five Core Values: Public Service, Integrity, Accountability, Excellence, and Respect. Specifically, CMS pledges surveyors to, among other things, "behave in the highest ethical manner, give information completely and honestly, and practice continuous quality improvement."

Linda Smith, MSN, RN, a CMS consultant on the project, emphasized the need for a sense of partnership between CMS and its providers, noting that the Core Values "help surveyors better understand the role of the survey process as part of our commitment to our beneficiaries, healthcare professionals, and partners." Smith also points out that "surveyors need evidence to support a finding of deficient practice in a facility," and that video clips are effective in emphasizing that.

In sum, the next time you undergo a state survey and find that it's gone a little more smoothly and consistently than before, you might owe some degree of gratitude to your professional colleagues at Sentara-Norfolk and the set designers and actors who "performed" there.

Tobi Schwartz-Cassell is a healthcare/business writer based in Cherry Hill, New Jersey. She is coauthor of the book Adding Value to Long-Term Care: An Administrator's Guide to Improving Staff Performance, Patient Experience, and Financial Health (Jossey-Bass, Inc., available from www.elderclinical.com). Contact Schwartz-Cassell at [phone]. For more information on this project, contact David Abraham of Sentara Nursing Center-Norfolk at [e-mail]; Jane McNally, RN at [e-mail]; or Catherine Morris, MS at [e-mail]. To send your comments to the author and editors, e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].