10 Tips to Go Above and Beyond in a Surgery Center Accreditation Survey

Preparing an ambulatory surgery center for an accreditation survey can be nerve-wracking, with so much paperwork to present and so many regulations to double-check. Sandy Berreth, administrator of Brainerd Lakes Surgery Center in Baxter, Minn., and a surveyor for the AAAHC, identifies 10 ways she has seen ASC administrators go "above and beyond" to impress a surveyor.

1. Present the most current standards handbook upfront. Ms. Berreth says she is always surprised by the number of surgery center administrators who don't own the current standards handbook for their accrediting body. "If your accreditation is for 2011, you're going to be accredited with the 2011 standards, not the 2009 or 2008 standards," she says. In an organization that wants to start preparing for accreditation now, that means purchasing a copy of the 2012 accreditation standards. She says while the majority of standards do not change from year to year, small changes can make the difference between a positive and negative outcome for a surveyed center. For instance, between 2008 and 2009, the AAAHC added a chapter on infection control standards to its handbook.

Ms. Berreth says when she walks into a center to start a survey, she usually says upfront, "Why don't you grab your handbook so that when we discuss standards, we'll be able to refer to your book?" She says if the surgery center administrator returns with a standards book that is two or three years old, that sets off a red flag in her mind. Make sure you have a copy of the most current standards handbook easily accessible in your surgery center so you're prepared to answer any questions about your compliance when the time comes.

2. Create a three-ring binder that demonstrates adherence to regulations. Ms. Berreth says she is always impressed when she walks into a center and the administrator hands her a three-ring binder containing a list of policies and procedures that follow the accrediting body standards "right down the line." She personally owns a three-ring binder divided into 13 sections. In each section, she has a list of the surgery center's policies, how they correspond with accrediting body regulations and how she can validate that the surgery center follows the standards.

For example, AAAHC regulations mandate that surgery center patients are treated with respect, consideration and dignity. The binder might list the regulation and then demonstrate that the surgery center enforces this policy by listing the ASC's methods: conducting patient satisfaction surveys, posting the policy in a clear place in the surgery center and rewarding staff with incentives for excellent customer service.

3. Include a table of contents in your binders. Make sure your ASC surveyor can find all the required information quickly by adding a table of contents to each binder, Ms. Berreth says. "If you don't have a table of contents, it makes it very, very difficult to pull out the policies we need to look at," she says. Including a table of contents will save you from rooting through several binders to find one sentence of information on your center.

4. Demonstrate that all your decisions go through the ASC board. Your surgery center should be able to demonstrate through meeting minutes that all decisions in the ASC go through board approval before implementation, Ms. Berreth says.

"If the administrator has the authority to make decisions in the surgery center, you have to have somewhere in your minutes that the board gives full authority to the administrator to conduct business," she says. She says this can be considered "the number one rule" for ASC accreditation since the release of the 2009 Conditions for Coverage by CMS. You must be able to demonstrate you take thorough minutes at your board meetings and save them for future reference.

5. Lay out 2-3 current quality improvement studies. Quality improvement studies don't need to be snazzy, but they do need to be current, Ms. Berreth says. Take two or three current quality improvement studies and present your process in an easy-to-read format. Include your goal at the beginning of the study and your results, including the data you collected along the way. If you take the time to present this information in an attractive, understandable format, your surveyor will appreciate it, Ms. Berreth says.

6. Know the answers to simple questions by heart. Brush up on simple, expected surveyor questions before the survey to show you've taken the time to prepare, Ms. Berreth says. 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.

7. Set up a space for the surveyor to work. If your survey is scheduled for a specific date — or you have a 90-day window when you know the survey will occur — you should be able to set aside some space for the surveyor to work. "You should always be able to prepare a space that's ready in less than five minutes," Ms. Berreth says.

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 says. While free Wi-Fi is not necessarily a "must" for surgery centers, it certainly helps a surveyor feel comfortable.

Ms. Berreth says the surveyor will also need a space to change into scrubs, as well as an unused pair of scrubs to conduct the clinical aspects of the survey. For surgery centers that don't have extra scrubs lying around, 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 says.

8. Involve a physician who cares about the survey. Nothing impresses an ASC surveyor quite like a physician who really cares about the survey process, Ms. Berreth says. Don't panic and think you need to involve your whole physician staff or your most well-known providers — she says one is enough to demonstrate teamwork at the center. Talk to your most involved physician before the survey date (if you know the date in advance) and ask him or her to come by the center to help answer questions.

9. Keep information brief — but know where to get more if needed. Every surveyor is different: Some will want to see every detail of your policies and procedures, and others will only want enough to demonstrate you meet standards. Keep everyone on the surveyor spectrum happy by presenting information in an abridged form, and letting the surveyor know you can bring more information if necessary. "During your 90-day window, whittle down what's important and put it in manageable binders," Ms. Berreth says. "You can always take the surveyor into your office and open up your built-in closet and say, 'Okay, now which organizational documents did you want?'"

10. Prepare a list of physicians and staff. Your surveyor will need to see some of your credentialing folders and personnel files, Ms. Berreth says. To make this process easier, prepare a list of all your physicians and a separate list of all your clinical and business office staff. You should also have a list of all contracted services. You can give this list to the surveyor and then provide credentialing information and personnel files based on the employees they select to review. For example, for contracted services, the surveyor may look at your list and then ask to see your laundry contracts specifically.

Related Articles on Accreditation:
CMS: Two Southwest Healthcare Hospitals Back in Compliance
Patient Safety Tool: Dos and Don'ts of Proper Sharps Disposal Poster
7 Statistics on Surgery Center Outcomes From the ASC Association

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