5 Areas That Trip Up ASCs During Accreditation Evaluations
1. Providing improper patient emergency preparation. ASCs must have the appropriate staff, equipment and medications to respond to a patient emergency situation. Surgery centers sometimes assume they stock appropriate supplies and medications, but that is not always the case, said Donna Tiberi, RN, a standards interpretation staff member with the Healthcare Facilities Accreditation Program.
"Some of the ASCs believe they're prepared for emergency situations, but actually they don't have the necessary pediatric equipment, such as EG intubation, blood pressure cuff sizes, pediatric unit dose medication, or nurses who are competent to respond to a patient emergency, such as advanced cardiac life support (ACLS) certification or pediatric advanced life support (PALS)," she said. "ASCs need to ensure they are prepared to stabilize their patients until the ASC can transfer the patient to the closest hospital or hospital of agreement."
Although ASCs may carry the necessary emergency equipment, they may not stock the required dosages of crucial medications, such as the mandatory Dantrolene to treat malignant hypothermia. "Some organizations don't carry the medication because it's expensive," Ms. Tiberi said. "The ASC must have all 36 vials available to address that emergency situation."
2. Failing to conduct facility-wide audits. Continuously conduct facility compliance audits so you know your center will be prepared when the surveyor arrives. AAAHC and Joint Commission have worksheets for ASCs to follow for these audits. Keep your facility compliance audits and use them to show ongoing quality improvement. Be sure to document the action plan when non-compliance is found, said Carla M. Shehata, RN, BSN, vice president of operations for Regent Surgical Health.
"At Regent, we do 13 intensive reviews per year so we make sure the facilities are ready for surveyors at all times," she said. "I would strongly suggest looking through any accrediting program's systems and standards, especially if they don't have a check-off sheet for survey readiness. Go standard by standard to make sure you are following all regulations and document how the regulations are met."
ASCs can also hire an outside survey consultant to work with them on compliance. While this person is often expensive, it can be beneficial for a fresh pair of eyes to examine the ASC.
3. Not designating a surveyor space. If your survey is scheduled for a specific date — or if you have a 90-day window when you know the survey will occur — you should be able to set aside space for the surveyor to work. "You should always be able to prepare a space that's ready in less than five minutes," said Sandy Berreth, administrator of Brainerd Lakes Surgery Center in Baxter, Minn., and a surveyor for the AAAHC.
This could mean the administrator's office or an unused office or empty conference room. The important thing is to make sure the surveyor has access to peace and quiet, as well as several outlets and Internet access. "Expect that your surveyor is going to be on the Internet, and expect that they're going to need to plug in their computer," she said. While free Wi-Fi is not necessarily a "must" for surgery centers, it certainly helps a surveyor feel comfortable.
The surveyor will also need an unused pair of scrubs and a space to change into them to conduct the clinical aspects of the survey. For surgery centers that don't have extra scrubs, she recommends purchasing a pair of extra large scrubs for surveyor use. "Small women can fit into extra large scrubs, but large men can't fit into small scrubs," she said.
4. Overlooking patient education. Patients and their families need to understand what is expected and required of them before the patient arrives for their surgery all the way through to the patients discharge, Ms. Tiberi said. "Sometimes a patient is not given a full explanation of their discharge instructions, or information is missing and staff must ensure that the patient understands the instructions which can be accomplished through return demonstration or repeat instructions."
The ASCs must gather and document the complete list of all medications as in prescription, over-the-counter or herbal medications that the patient is currently taking. "This must be documented in the medical record before administering anesthesia or prescribing new drugs," she said. "Sometimes patients don't know or remember what medications they're using. In that case, a family member can provide this information or the patient can bring in their medication bottles with them. Regardless, you must make a good faith effort to collect medication list information."
5. Not knowing simple answers by heart. Brush up on simple, expected surveyor questions before the survey to show you've taken the time to prepare, Ms. Berreth said. For example, the surveyor will probably ask how many quality improvement studies you conducted this year, last year and the year before that. Don't stand there trying to count up the number of studies in your head; count them before the surveyor arrives so you can rattle off your answers professionally. You should also know the kind of benchmarking your surgery center performs and your most recent internal benchmarks for staff hours per case, days in A/R and other common ASC statistics.
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