By Tricia Dixon-Thomas

When the time comes for your healthcare facility’s accreditation survey, your stress levels may rise, but with a little preparation and continual organization, you can always be ready. Maintaining readiness ¬– whether for an Initial Accreditation Survey, a Reaccreditation Survey, a Focused Survey, complaints, or CMS regulators – proves essential because a Surveyor can show up unannounced at your ambulatory surgery center.

The Accreditation Commission for Health Care Ambulatory Surgery Center (ASC) Accreditation process relies on a survey designed to be a meaningful assessment. The Surveyor evaluates an organization’s compliance with ACHC Standards and national patient safety goals as indicated by the Centers for Medicare & Medicaid Services (CMS ). The survey ensures high-risk issues are identified and the process of developing strategies to mitigate those risks can begin.

Poor survey performance can jeopardize your licensure, Medicare certification, and/or accreditation. Lose any of these and you are looking at a loss of insurance contracts and patients.

You can avoid negative happenings by staying up to date through organization and education. Take a look at some simple ways you can keep your center survey ready.

Start By Becoming Familiar With All Standards

First is making sure you have ACHC’s most up-to-date Accreditation Requirements for Ambulatory Surgery Centers standards manual. Resources can be found through your Compass account in the ACHC customer portal. Become familiar with the standards by reviewing all of them.

Organization is essential. Create and maintain a binder for each chapter of the manual, and use tabs for quick references. Behind the tabs, place supporting documents that need to be updated monthly and quarterly and reported on during your Governing Body meetings.

Organize Documents for Accessibility

No doubt you already have your Policies and Procedures documents organized for reference and for access during your survey. Here are more binders you can organize for viewing during the survey process.

Governing Body (Chapter 1): Place your Governing Body Meeting Minutes for the previous 12 months behind your Policies and Procedures. This chapter would also include your Articles of Incorporation, Mission Statement, List of Contracted Services (showing monitoring), and Quality Assessment and Performance Improvement (QAPI) and Performance Improvement (PI) projects. Develop a template for your meetings that addresses oversight on the required board topics, such as Credentialing, Infection Control, QAPI/PI, Policy and Procedure review, etc. (Review the standard-required topics.) Surveyors will review minutes from the previous four quarters to show all compliance efforts are tied back to the Governing Body.

Human Resources (Chapter 2): All personnel, including contracted staff and PRN staff, must have personnel files that have current job descriptions, licenses, competencies, and training/continuing education units (CEUs). Because staff start at different intervals throughout the year, random audits of these files will be useful to make sure files are being updated regularly.

Medical Staff (Chapter 3): Having a checklist from the standard will ensure compliance when you are credentialing your medical staff, whether for the first or 20th time. Organizing the documents in the same way helps with consistency and keeps required items accounted for.

Quality Assessment Performance Improvement (Chapter 4): The ASC must develop and maintain an ongoing, data-driven QAPI Program. Keep PI data readily available in binders for the Surveyors, and include how the projects are coordinated and evolving over the year. Meeting minutes should show data being presented to the Governing Body and reviewed for continuous improvement.

Infection Control (Chapter 5): The Infection Control program should encompass all departments and services within the center. Tracking should be well documented and shared in the QAPI and Governing Board meeting minutes. Surveyors will be assessing the center for cleanliness top to bottom – from condition of ceiling tiles to quality of flooring, including breaches in seams. All drugs and supplies must be stored, labeled, and used correctly. The sterilization process must be followed, and staff will be interviewed to ensure they have proper training. All cleaning products and dilution ratios will be observed, so education of staff is essential.

Medical Records (Chapter 8): Clinical records must be stored in locations that prevent access by unauthorized individuals and are secure from fire or disaster.

Additional Binders: Create binders to house all of your reports and logs for easy access. Preventative maintenance logs, temperature and humidity logs, refrigerator logs, incident logs, and transfer logs can be organized in binders for easy reference.

The binders listed above are just a few examples of ways to keep you and your center survey ready.

Make Monitoring the ASC’s Environment a Daily Habit

When it comes to an ambulatory surgery center’s environment, daily monitoring is key. Making sure the daily standard requirements are being addressed:

• Temperature and humidity are monitored and logged.

• Corrugated boxes are not left in the center or in storage areas.

• Medications are secured.

• Pull stations and medical gas panels are free from obstruction.

• General cleanliness of the center is being addressed.

Doing all of these will help maintain a safe working and patient care environment. Make a list of monthly inspections that need to take place, and try to keep those on the same day of the month for consistency.

Test Yourselves With a Mock Survey

One of the best ways to prepare for a survey is to conduct a mock survey. A staff member acts as a Surveyor, putting themselves into a patient’s shoes and tracing that experience from admission to discharge.

The mock tracer assesses the existing state of compliance, with all activities conducted with mock tracer tools available among the resources provided through your ACHC customer portal.

Quiz staff members by asking Surveyor-type questions. If a staff member doesn’t know an answer, you may have identified an area for additional education and/or training.

DON’T DO THIS ALONE!

Make involvement in the accreditation process part of the job description for each team member, including physicians. The whole team should be familiar with standards and policies − because completing a successful survey takes the whole team.

The importance of having physicians involved cannot be overstated. For example, surgeons and anesthesiologists can evaluate oversight of standing orders, crash cart items, patient selection, privileging, emergency management, and process improvement activities in those and other areas.

Making this a team approach will ensure that your ambulatory surgery center maintains a constant state of survey readiness.

Here to Help

We are ready to assist. If you have questions or need help accessing the most recent Accreditation Requirements for Ambulatory Surgery Centers, contact your Account Advisor, email [email protected], or call (855) 937-2242.