10 Common Roadblocks to Achieving Surgery Center Accreditation

Donna Tiberi, RN, a standards interpretation staff member with the Healthcare Facilities Accreditation Program, discusses 10 common roadblocks observed during the surveying process of achieving ambulatory surgery center accreditation.

1. Credentialing and privileging. The educational background and training of all physicians must be verified before granting privileges, says Ms. Tiberi. The surgery center also should not assume that hospital privileges qualify the physician to perform procedures in the ambulatory setting. "Sometimes people forget about this," she says. "For example, organizations will grant privileges for GI services, but the ASC must clearly delineate the specific privileges approved for the GI practitioner to perform in the ASC setting. You can't take a hospital list of approved privileges and approve the same privileges for the ASC setting."

2. Primary source verification. The ASC's leadership must conduct a primary source verification of the physician's background through the American Medical Association, American Board of Medical Specialties, American Osteopathic Association, Educational Commission for Foreign Medical Graduates or Federation of State Medical Boards, says Ms Tiberi. The American Academy of Physician Assistants and National Commission on Certification of Physician Assistants can be consulted for physician assistants.

3. Obtain professional references. An ambulatory surgery center should request at minimum at least three professional references confirming the physician's experience, qualifications, character and judgment, says Ms. Tiberi. The references should attest that the physician worked at a particular hospital, completed a residency and performed specific procedures. "This is usually done in the form of a letter and verifies that the physician is trained, qualified, and competent," says Ms. Tiberi.

4. Patient emergency situations preparation. ASCs must have the appropriate staff, equipment and medications to respond to a patient emergency situation. A surgery center may sometimes assume that they stock appropriate supplies and medications, but that is not always the case, says Ms. Tiberi. "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 says. "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," says Ms. Tiberi. "The ASC must have all 36 vials available to address that emergency situation."

5. Hand hygiene guidelines. Infection control training and education for the ASC is vital, Ms. Tiberi says. "The ASC must follow current hand hygiene practice guidelines such as the CDC or WHO guidelines. During survey, the surveyors will be observing staff hand hygiene and protocols and may interview the staff," she says. Staff must be educated on hand hygiene guidelines and follow them consistently.

6. ASC equipment sterilization and disinfecting. The ASC should clean and sterilize all equipment in accordance with CDC HICPAC guidelines. If the ASC contracts with an outside vendor to perform sterilization for their equipment, it must ensure that its contract agreement follows CDC HICPAC sterilization guidelines, says Ms. Tiberi.

Staff members assigned to disinfect and or sterilize equipment in the ASC must always follow the manufacturer's requirements for maintenance and care. Rapid or "flash" sterilization of equipment is not prohibited, but should not be performed on a routine basis in place of a full sterilization, says Ms. Tiberi. The ASC must maintain a written or electronic log of all sterilized equipment so that the center can track infection rates and or notify any affected patients if a sterilization malfunction is discovered, she says.

7. Wrong site surgery. The ASC is required to conduct a standardized "time out" process before every surgical procedure to ensure that the right patient, right procedure, right equipment, right medications, right surgical marking and the right physician are present. The surgical site is to be marked by the surgeon with a standardized surgical marking.

A "time out" checklist is required to be used to ensure that all of the time out steps are consistently followed, says Ms. Tiberi. "Sometimes the time out process is being performed, but staff fail to document it, or elements of the time out are missing," she says. "When a surveyor is on site, they will review charts to verify that time-out was documented." Ms. Tiberi adds that the verification process should begin from the time a patient is scheduled for a procedure through to the time of surgery. "You always want to ensure that you have the right patient," she says. "You need to follow consistent policies, and procedures."

8. Patient education process. 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, says Ms. Tiberi. "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 says. "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."

9. Medication log: all medications taken in and out of the facility. The surgery center should maintain a log for all controlled medication brought into the facility. "These medications are considered controlled substances," says Ms. Tiberi. "Staff are required to ensure that they sign all controlled medications in and out. ASCs must follow state and federal law and regulations for all controlled medications. Usually facilities maintain a medication log to monitor use and administration. Staff must verify controlled medications levels — usually these controlled substances are counted before the start of cases and at the end of the day by two staff members, and all wasted controlled medications have a witnessed signature." Only those employees designated, licensed and authorized by their state law and facility policy may access medication, she says.

10. Waived tests. Facilities performing waived testing — such as blood sugar levels, urine dipstick or urine pregnancy tests — must have an up-to-date clinical laboratory improvement amendments certificate (CLIA certificate) , says Ms. Tiberi. All staff members performing waived testing must be competent and trained to perform the facility list of waived tests, she says.

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