A cautionary note: Those days of knowing when surveyors or government regulators are coming and having time to prepare? They’re long past, say accreditation experts interviewed by Same-Day Surgery.
Surveyors and regulators can decide to do a survey for risk management reasons, to examine your adherence to life safety regulations, or to conduct a more focused inspection, cautions David Shapiro, MD, CASC, CHC, CHCQM, FABQAURP, FAIHQ, LHRM, a board member for the Accreditation Association for Ambulatory Health Care (AAAHC). For that reason, don’t wait for your accreditation cycle to approach its expiration date, Shapiro says.
“Those folks have the ability … to show up any day of the week you’re open,” he says. “You want to be ready when they get there.”
The preparation is particularly important because the Office of Inspector General (OIG) of the Department of Health and Human Services has added ambulatory surgery centers to its Work Plan for this year. OIG has expressed concern about the infrequency of Medicare certification surveys for ASCs. (See more information in this month’s issue of Same-Day Surgery.)
Consider these suggestions for being survey-ready:
• Have a solid education program.
The reason for most survey deficiencies is that employees either aren’t aware of the requirements or they skip steps in the process because they aren’t focused, says Jan Allison, RN, CHSP, director of accreditation and survey readiness at Deerfield, IL-based Surgical Care Affiliates.
“Educate teammates in understanding their responsibilities, including their role before, during, and after survey,” Allison says. “They need to be aware of current standards and common survey citations.” (See list of AAAHC most common deficiencies in this issue of SDS Accreditation Update. The Joint Commission’s most common deficiencies are available at bit.ly/1lW8cjv.) She points out that during a survey, surveyors follow a tracer methodology by selecting a patient and assessing the patient’s experience from check-in to discharge.
“Teammates from various departments within a facility are involved in sharing with surveyors how they fulfill the standards through their day-to-day responsibilities,” Allison says. “Each teammate needs to be knowledgeable of the important issues and have a clear understanding of the regulations/standards that apply to their job and department.”
Surgical Care Affiliates records webinars about survey readiness and posts them on its eLearning system. Employees who watch webinars earn continuing education credit. (AHC Media, publisher of Same-Day Surgery, also offers webinars on accreditation topics. See list of webinars at bit.ly/1JCREbM.)
“Monthly newsletters or posters addressing updates work to keep teammates current,” Allison says.
• Delegate responsibility.
Accreditation is a lot of work, so spread it around among employees, Shapiro advises.
“All of them should have skin in the game,” he says. “If you divide up the work, it’s a much less daunting task, instead of putting on one person’s shoulders who has other responsibilities and may be taking care of patients 12 hours a day.”
Allison concurs that accreditation needs teamwork. “One person alone cannot effectively drive compliance,” she says.
• Be familiar with the standards, and cross- reference them to your policies.
On site, you should have current state-specific regulations, the Centers for Medicare and Medicaid Services State Operations Manual, and the most current version of the accreditation manual, Allison says. “Be familiar with their contents,” she says.
Shapiro concurs. “It’s an open-book test,” he says. “You will not be surveyed against anything that you shouldn’t have easy access to and more than passing familiarity.”
Many organizations have found it helpful to index their policies or cross-reference them to specific standards, Shapiro says. When a surveyor asks about a specific standard, a cross-referenced document will allow you to search for the specific standard, he points out.
• Use tools and processes to ensure compliance.
Many outpatient surgery programs struggle with documentation that shows required activities took place, Allison says. “This may be in the form of missing elements in the governing body meeting minutes or in the reports from vendors that conduct maintenance and testing,” she says. “We have to remember that documentation tells the story of the activities taking place in the facility and, in a number of situations, that is all the surveyor has to look at.”
Surgical Care Affiliates uses meeting minute templates that are preprinted with topics, in bulleted form, that will be discussed, Allison says. “Spreadsheets or software is implemented that prompts for a required activity to take place just prior to being due,” she says.
Shapiro says that monthly, or at least quarterly, you should perform self-assessment of accreditation problem areas, such as credentialing and personnel records, “those mountains of paperwork that surveyors go through, such as peer review files.” Ensure they are current on an ongoing basis, he advises.
Allison says compliance audits “ensure teammates are knowledgeable over basic standards and are performing processes appropriately, that facility policies reflect current best practices, the environment is safely maintained, and documentation is current and complete. Audit checklists contain key observations used to determine the extent to which standards are being followed in designated areas.”
Your QA/PI program should be robust, she says. “This is where audit results are initially reported and analyzed and corrective actions are developed and implemented for improvement,” Allison says.
Use a “tickler” program for yourself or the staff members who handle survey responsibilities as reminders of deadlines, Shapiro says. “If physician credentialing files are up for recredentialing, start six months ahead, not two months after, when you have to hold up bookings,” he says.
Accountability is key, Allison says. “Vendor contracts need to reflect the required inspections, maintenance, and testing and the frequency with which they occur,” Allison says.
Conduct mock surveys on a regular basis by acting in the role of surveyor and looking at protocols as a surveyor would, Shapiro advises. Mock surveys can be held on just a few regulations or standards, such as patient handoff protocols or the fire safety system. Use the surveyor worksheets, Allison adds.
By following these steps, Shapiro says, you “keep your facility up to date in every regard that pertains to a survey so you’re never playing catchup."
When the surveyor walks in the door, you want to be ready and up to date, “not behind the eight ball, not scrambling around,” he says. “Everything is polished and ready to go.”
AAAHC’s Most Common Deficiencies for ASCs
• Safe injection practices
Standard 7.1.C.2 Subchapter I Infection Prevention and Control: An accreditable organization maintains an active and ongoing infection prevention and control program as evidenced by the following characteristics: C. The infection control and prevention program reduces the risk of health care-acquired infection as evidenced by education and active surveillance, consistent with: 2. CDC or other nationally-recognized guidelines for safe injection practices.
• Credentialing, Privileging and Peer Review
Standard 2.11.D Privileges to carry out specified procedures are granted by the organization to the health care professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. These privileges are granted based on an applicant’s qualifications within the services provided by the organization and recommendations from qualified medical personnel.
Standard 2.11.H The results of peer review are used as part of the process for granting continuation of clinical privileges, as described in Chapter 2.II.
Standard 2.11.B.5. Medical staff must apply for reappointment every three years, or more frequently if state law or organizational policies so stipulate. At reappointment, the organization requires completion of a reappointment application and verifies items listed in Standards 2.II.B.3.c-g and peer review activities as described in Chapter 2.III.
• Quality Management and Improvement Standards
Standard 5.1.C and Standard 5.1.C.2 The organization demonstrates that ongoing improvement is occurring by conducting quality improvement studies when the data collection processes described in Standard 5.I.B indicate that improvement is or may be warranted. Written descriptions of QI studies document that each study includes the following elements as applicable: 2. Identification of the measurable goal against which the oganization will compare its current perfomance in the area of study.
• Documentation
Standard 6.F. The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistently defined location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified.
SOURCE
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Accreditation Association for Ambulatory Health Care, Skokie, IL.
