This language in 416.41 is as follows:
“…The governing body has oversight and accountability for the quality assessment and performance improvement program, ensures that the facility policies and programs are administered so as to provide quality healthcare in a safe environment…” It further goes on to explain, “…The ASC must have a designated governing body that exercises oversight for all ASC activities. The governing body is responsible for establishing the ASC’s policies, making sure that the policies are implemented, and monitoring internal compliance with the ASC’s policies as well as assessing those policies periodically to determine whether they need revision…” “…the ASC’s governing body retains the ultimate responsibility for the overall operations of the ASC and quality of its services. The regulation also emphasizes the governing body’s responsibilities in the areas of QAPI and disaster preparedness. Delegations of governing body authority should be documented in writing. The governing body is responsible for creating a safe environment where ASC patients can receive quality healthcare services. This means the governing body is not only responsible for adopting formal policies and procedures that govern all operations within the ASC, but also that it must take actions to ensure that these policies are implemented…”
During the surveying procedure the CMS surveyors must seek information regarding
• Ask to see meeting minutes or other evidence that the ASC’s policies and procedures have been formally adopted by the governing body.
• Ask to see meeting minutes or other evidence of how the governing body assures that its policies are implemented, and of how the governing body monitors internal compliance with and reassesses the ASC’s policies. For example, is there any evidence of data collected and submitted to the governing body related to specific ASC policies?
• Ask to see meeting minutes or other evidence of how the governing body exercises ongoing oversight of and accountability for the ASC’s QA/PI program.
To help meet these requirements, Ms. Berreth uses a compliance reporting form which documents compliance requirements such as continued competencies and audits performed. “This brief compliance reporting document keeps the governing body engaged,” she says. Ms. Berreth sends one of these reports on a monthly basis, via e-mail, to each of the ASC’s board members. Then she has a quarterly review in the packet she assembles for the board.
To view a sample version of the compliance reporting form used at Brainerd Lakes Surgery Center, click here.
