Sheryl Walker, MD, who has been a surveyor for the Accreditation Association for Ambulatory Health Care for more than 15 years, shares the follow five best practices for ambulatory surgery centers to meet the Medicare Conditions for Coverage (CfC).
1. Support team member assigned to CfC. Dr. Walker says the most important step to an ASC meeting the CfC requirements is to give full support to the member(s) of the team assigned to ensuring the surgery center is following the rules. "By supporting I mean allowing them the time off and in some cases supporting them financially to go to conferences and educational seminars so this person can understand what the implications are of the CfC and can then go back and implement them in their own facility," she says. "It also means being receptive to what this person learns and says."
2. Prioritize governance. During a survey, Medicare — like the accrediting bodies — will usually look very closely at the role of the governing body in the ASC's operations. The requirements for the governing board are significant and they can challenge any organization, particularly smaller facilities with small governing boards which still must meet the many rules regardless of their size, says Dr. Walker.
Here are just some of the questions Dr. Walker says an ASC's governing board needs to answer positively to stay in compliance with the CfC:
- Does the governing board know its responsibilities?
- Are these responsibilities, possibly in the form of policies and procedures, documented?
- Does the governing board meet to discuss credentialing? Are these meetings documented?
- Does it review and is it involved with a quality improvement program? Is this documented?
- Does it follow the appropriate steps for allowing a physician to perform procedures at the ASC? This can include confirming proper training, reviewing credentialing, adding procedures to the surgeon's delineation of privileges list and adding them to the ASC's list of approved procedures. All of these components need to undergo review and approval by the board, with everything documented.
- Does the ASC have the appropriate equipment and staffing to perform the new procedures? Are the staff members trained on the procedures? Did you confirm they were in-serviced or have received training on the procedures? Is this all documented?
- Does the ASC have policies and procedures in place to handle potential complications that may arise from a new procedure and do so appropriately, either by your facility or, if need be, transferring the patient to another facility? Are these processes documented?
A reoccurring theme with meeting these requirements is documentation. "Everything needs to be documented, regardless of how big or small you are," says Dr. Walker. "This is all to protect the patients who are coming in to have procedures done. It's so easy to forget that you're not in a hospital with all of its multi-levels of backup. When you're by yourself, it falls on your shoulders as a governing body."
3. Perform ongoing QI activities. An ASC is expected to perform ongoing QI studies and benchmarking, Dr. Walker says. One particular area of focus for QI should be complications and adverse events.
"You should be tracking complications so you know what areas you need to improve on and be seeking out that information so you can use it as part of your QI program," she says. "Has your ASC identified what is an adverse event and does it have a policy to address adverse events? You have to already have an established process in place where you're looking at every complication on every procedure every day.
"Hopefully you won't have any but if you're not looking and you're not documenting, you won't have any idea how many times a patient needed to be treated for something other than routine care," Dr. Walker says.
4. Identify applicable requirements before construction. One of the biggest challenges ASCs face in meeting the CfC requirements concern building/structural issues which must be addressed during construction of a new facility or expansion of an existing one, says Dr. Walker. This can includes requirements relating to medical gas rooms and oxygen supply lines.
While existing facilities may be grandfathered in to some requirements and changes made to the CfC (it's critical to confirm whether this is the case), new facilities or facilities undergoing expansion likely would not, she says. As such, you will want to identify what your facility needs to do to be compliant when construction is completed or it could cost you.
"Those are expensive things to change," says Dr. Walker. "It's a lot harder to tear down walls and reroute oxygen supply lines than getting it right the first time."
5. Select appropriate architect. One valuable step a surgery center can take to help ensure it meets CfC requirements during construction is to hire an architecture firm with architects dedicated to medical facilities.
"That person you select has to be familiar with the Medicare Life Safety Codes," says Dr. Walker. "If you don't have that, chances you may not be in compliance with the building regulations and that's huge. Some of your accrediting bodies may be able to help you with finding such an architect who is familiar with it or you can talk with other facilities that are up in operation and met the appropriate building codes" and find out who they hired.
Learn more about AAAHC.
Read more about the Conditions for Coverage:
- Would Your Facility Pass an Infection Control Survey?
- 7 Stories on Achieving and Maintaining Medicare Certification
- 10 Recent Changes in How CMS Surveyors Deal With Surgery Centers