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Clinical Leadership Has an Essential Role in Nursing Services for Surgical Settings
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September 17, 2024
Clinical leadership is a critical role for ensuring patient safety in the surgical setting, and, in many cases, it’s a requirement of state and federal regulations.
This important responsibility starts long before the patient enters the surgery facility and well in advance of the application of general patient safeguards: right patient, right medication, and right surgery. It starts with making sure strong leadership is in place to direct patient care and ensure appropriate staffing to meet patient needs.
Choosing the Right Person for the Role
Make certain that the individual appointed to this leadership role has a solid background and has the clinical experience needed to oversee the demographic population you serve. In some settings, this individual may function in more than one role, so it is necessary to have someone who understands patient care and is given the resources needed to provide a safe environment and contribute to the facility’s success.
When you’re thinking about the responsibilities that go along with overseeing clinical care and the type of person you need to choose for the leadership role, it may seem like an enormous task, but remember that it can also be extremely rewarding to know you’re playing an intricate part in patient safety and contributing to the environment that allows surgeries to now be performed safely in the outpatient setting. Some essential duties for this hire may include staff scheduling, competency assessments, infection control and prevention, and maintenance of medical supplies and equipment.
Where Some Organizations Fail to Meet Standards
When conducting accreditation surveys, ACHC Surveyors are finding that some deficiencies relate to the leadership appointment process and leadership roles.
- Lack of formal appointment of the person selected to direct clinical services by the organization’s governing body.
- Failure to ensure the person assigned to this position is a Registered Nurse or has the training and the experience to perform the role.
- Lack of a job description for this position.
- Lack of documented orientation for staff responsible for patient care.
- Lack of clinical competencies.
ACHC Standards provide guidance and structure in helping your ambulatory surgery center achieve success.
02.00.03 Condition for Coverage: Nursing Services
The nursing services of the ASC must be directed and staffed to assure that the nursing needs of all patients are met.
Note: This is a CMS condition level requirement.
- CMS Condition for Coverage: §416.46
- Documentation is present of the designation of an RN to direct nursing services.
- Sufficient nursing staff with the appropriate qualifications must always be available to ensure the nursing needs of all ASC patients are met. This implies that there is an ongoing assessment of patients’ needs for nursing care and that identified needs are addressed.
- The numbers and types of nursing staff needed will depend on the volume and types of surgery the ASC performs.
02.00.04 Nursing Services Staffing
Patient care responsibilities must be delineated for all nursing service personnel.
- Nursing services must be provided in accordance with recognized standards of practice.
- A registered nurse must be available for emergency treatment whenever a patient is in the ASC.
- CMS Condition for Coverage: §416.46(a)
When conducting accreditation surveys, ACHC Surveyors are finding that some deficiencies relate to the leadership appointment process and leadership roles.
- Lack of formal appointment of the person selected to direct clinical services by the organization’s governing body.
- Failure to ensure the person assigned to this position has the training and the experience to perform the role. In the non-deemed setting, this person may need to function in multiple roles.
- Lack of a job description for this position.
- Lack of documented orientation for staff responsible for patient care.
- Lack of clinical competencies.
ACHC Standards provide guidance and structure in helping your office-based surgery facility or non-deemed ambulatory surgery center achieve success.
02.00.03 Patient Care Services Director
- The services of the organization must be directed and staffed to ensure that all patient care needs are met.
- Sufficient staff with the appropriate qualifications must always be available to ensure the needs of all patients are met. This implies there is an ongoing assessment of patients’ care needs and plans to meet identified needs.
- If no individual is designated to provide oversight of the patient care services, policies and procedures provide guidance.
- The numbers and types of staff needed depend on the volume and types of procedures the organization performs. The supervision of non-licensed staff ensures that they have appropriate oversight by a designated individual.
Tips for Compliance
- Ensure the individual assigned to this role is familiar with all relevant healthcare regulations, accreditation standards, and licensure requirements.
- Keep complete and thorough documentation on clinical staff in the human resources file. Examples include competencies, training, and documented experience of both leader and staff.
- Ensure staff are qualified for the tasks they are assigned to perform.
- Institute a clear delineation of responsibilities for this leadership position that meets all regulations.
- Track and trend patient feedback on the care they received and adjust actions to address any patient concerns.
Here for You
ACHC is your partner in accreditation. Clinical Laboratory Accreditation. For information on information, contact your Account Advisor, email [email protected] or call (855) 937-2242.