Babak Arvanaghi, MD, is an ASC pain management physician and founder of Basha LLC, a software company focused on creating a suite of web-based document management system applications, including the ASCpro regulatory compliance document management application. ASCpro was developed specifically for ASCs and is designed to automate an ASC's compliance, credentialing efforts and documents and allow surgery center administrators and management companies to view and understand where their ASCs stand in meeting regulatory compliance requirements. Q. What are the biggest challenges ASCs face to meet current regulatory requirements?
Dr. Babak Arvanaghi: Current regulatory requirements take special aim at prevention of infections and safety issues. ASCs are expected to have a comprehensive infection prevention and control plan that has been approved by the governing board and meets guidelines from CDC, WHO or other recognized entities. Hand hygiene, sterilization practices and sharp injury prevention are of particular interest. Documentation of annual staff training must be current. Surveillance and monitoring of these practices should be an integral component of the center's quality improvement program.
Recently, a fully accredited ASC was fined by OSHA for lack of policies to prevent, treat and report sharp injuries (Outpatient Surgery Magazine, Vol. XIV, No. 3, March 2013). Compliance with the many regulatory and accreditation bodies at the ASC level is becoming a full-time job much like in the hospitals. Although the resources and the budget for compliance in an ASC is a fraction of those in the hospitals, ASCs are nonetheless expected to follow the same rules and standards. With the decrease in the reimbursements, ASC administrators will need to find cost-effective ways to comply with these regulations.
Q. How can ASC leaders ensure these regulatory challenges are met?
BA: Ever-changing regulatory and accreditation standards require updates to existing policies and procedures, preferably in real time. Many ASCs assign administrative duties to the most experienced nurse who is also responsible for coordinating clinical activities and may from time to time be asked to assist in cases. In that event, the administrative task is usually the first to be neglected. A system that provides for built-in reminders and access to the latest data and regulations, such as ASCpro, is ideal for concentrating policies, procedures, credentials, training records, inventory, expiration dates and testing of equipment.
Automated programs can be beneficial because instead of accumulating multiple volumes of outdated policies, management and staff can access items of particular interest to them at any time.
Q. What type of physician and staff education is necessary to ensure compliance?
BA: It is indispensable that physicians become an integral part of the ASC's leadership. They provide the professional input that assures a smooth functioning entity. On the other hand, physicians are often not familiar with specific regulatory and accreditation requirements. One technique to bring everyone up to date is to organize an annual "retreat," preferably with a moderator, away from telephones and other interruptions. This is of particular importance since eventually all policies need to be approved by the governing board, which consists of physicians/providers. An additional approach is to have all physicians rotate through various committee assignments to allow for ongoing familiarization with administrative processes. With the use of compliance software, the administrators can also keep the physician and staff up-to-date on the latest regulatory issues.
Q. Where do you see regulatory and compliance trends heading in the future for ASCs?
BA: It is to be expected that enhanced inspections by CMS, CLIA, OSHA and accrediting agencies will take place. To a great extent, headline-grabbing incidents, such as post-operative infections, wrong-site surgery, improper use of implants, misinterpretation of test results and work-related injuries are important drivers of these steps. Of particular interest, currently, and especially to CMS, is the evaluation of the benchmarking and QI programs, documentation of staff training and testing of equipment. CLIA emphasizes compliance with proper performance of tests as described by manufacturer's instructions. Annual changes of accreditation standards are a given, so that entities must be prepared to comply with the current version when undergoing an accreditation survey.
Keeping up with all these regulations, standards and the new areas of focus requires a large percentage of the administrator's time. With the use of an automated compliance software system, the administrators can share those responsibilities with the other members of that ASC community, ensuring adherence with the standards in an efficient way. A mock survey, which is a built-in feature of the ASCpro, will prove to be especially helpful.
Learn more about ASCpro at www.ascpro.com.
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