Strengthening Quality and Confidence for a Successful Survey
Challenge
Orleans Community Health – Medina Memorial Hospital, a Critical Access Hospital (CAH in New York, faced significant challenges in preparing for an upcoming Department of Health (DOH) survey. Recent administrative changes and shifting job responsibilities had left the hospital without a fully developed quality program, and a mock survey by Stroudwater revealed gaps in the hospital’s readiness.
At the time, Medina Memorial leadership did not realize they had readily available external support and had not explored consulting options. The hospital’s Chief Nursing Officer (CNO), Kim Gray, recognized the urgent need for structured support and turned to Stroudwater for guidance.
Why Stroudwater?
Stroudwater’s expertise in rural and CAH compliance made it the ideal partner to support Medina Memorial in its survey preparedness. Their comprehensive survey readiness approach, deep understanding of CAH regulations, and ongoing support network provided a level of guidance that Medina Memorial had not experienced previously.
Process
Stroudwater implemented a rigorous mock survey, treating it as a realistic survey scenario. Their process included:
- Chart reviews to assess documentation accuracy
- Staff interviews to gauge compliance awareness
- Full mock survey execution to identify gaps
- Immediate feedback and resources to address deficiencies
- Comparison with previous surveys to pinpoint areas for improvement
Additionally, Stroudwater provided resources from the federal register, ensuring Medina Memorial clearly understood compliance standards.
Results
The impact of Stroudwater’s support was significant, including the following improvements:
- Stronger Leadership in Quality: The mock survey process helped establish a dedicated Director of Quality role, previously overseen by the CNO without RN support.
- Greater Team Confidence: Staff entered the DOH survey with a renewed sense of preparedness and clarity on expectations.
- Ongoing Support Beyond the Survey: Stroudwater’s engagement did not end after the mock survey. Their consultant, Carla Wilber, provided ongoing training, guidance, and policy resources tailored to Medina Memorial’s needs.
- Enhanced Knowledge Sharing: Stroudwater connected Medina Memorial with other CAHs statewide, creating an invaluable support network.
A Lasting Partnership
Stroudwater’s commitment to Medina Memorial Hospital extended well beyond a single engagement. Their ongoing support has ensured the hospital continues to refine its quality program, regulatory compliance, and overall survey preparedness.
“The continued support has been absolutely amazing. Carla has taken us under her wing, scheduling ongoing training, answering questions, and even sharing policy examples. We truly appreciate the resources Stroudwater provides—it has made all the difference.” – Melanie McAdoo, Director of Quality
Conclusion
Medina Memorial Hospital’s successful survey readiness journey highlights the value of proactive preparation, expert guidance, and sustained partnership. By working with Stroudwater, the hospital has strengthened its quality program, built confidence among staff, and established a roadmap for continued compliance success.
