Jim Stilley, CEO of Northwest Michigan Surgery Center in Traverse City, Mich., outlines six steps ASCs can take in order to be better prepared for a visit by a surveyor from an accreditation organization.
1. Form a diversified committee charged with tackling specific accreditation issues. By forming committees of subject-matter staff member experts who actively tackle issues related to accreditation standards, an ASC can better position itself for a more successful survey.
"Those committee members take what surveyors are going to look at and roll through each chapter of the accreditation standards, evidencing that we're aligned with those standards," Mr. Stilley says. "One of the chapters includes information about patient rights, so we want anyone involved in the process of patient intake to be involved in that committee, including the front desk personnel and registration department."
2. Compile specific policies and procedures. Committee members at Northwest Michigan take standards established by various accrediting bodies, including the Accreditation Association of Ambulatory Health Care and CMS, discuss exactly how the surgery center will work to meet that standard and publish them in a manual that is kept in a room accessible to any staff member who needs to view it.
3. Assemble the policies and procedures in an organized fashion. Mr. Stilley says the manual containing the surgery center's established policies and procedures is brought together in a very organization fashion. He says every chapter, which tackles each standard one by one, is outlined in the same fashion.
"The policies and procedures are all kept in a three-ring binder," he says. "So any staff member can open to any chapter, such as Chapter 1, Rights of the Patients, and is immediately able to read the exact verbiage of the standard established by an accrediting body."
4. Evidence compliance to standards. One of the challenges of an accreditation survey is the different subjectivities amongst surveyors about how a surgery center achieves compliance to a standard. Mr. Stilley says to combat this, his surgery center evidences compliance directly in the manual.
"If a surveyor asks to be shown how we meet any standard, we can go right down to the exact chapter and subsequent subchapters and say 'Here's 15 ways we are meeting this standard' and then document detailed examples of how we carried those actions out," He says.
5. Provide quick go-to guidelines for staff members. Included in the manual before each chapter are quick go-to guidelines for staff members to read on established policies and procedures. This avoids the need to read through official verbiage and long explanations of policies and procedures in the case a staff member needs a quick overview.
"Each committee has to put together quick bullet points on what the most essential points are about the subsequent topics," Mr. Stilley says. "For example, before the first chapter about patients rights begins, there is a sheet with bullet points asking 'Did you know' questions, including 'Did you know Northwest Surgery Center has a website with information on how to contact the facility and its privacy policies?'"
6. Develop a system of accountability. Since every chapter is put together by a formal committee, Mr. Stilley developed protocol requiring committees to put together a list of names of staff members in the committee and staff members responsible for reviewing the chapters. The review of records build better accountability for those responsible for putting the chapters together and disseminating the knowledge throughout the facility.
Learn more about Northwest Michigan Surgery Center.
1. Form a diversified committee charged with tackling specific accreditation issues. By forming committees of subject-matter staff member experts who actively tackle issues related to accreditation standards, an ASC can better position itself for a more successful survey.
"Those committee members take what surveyors are going to look at and roll through each chapter of the accreditation standards, evidencing that we're aligned with those standards," Mr. Stilley says. "One of the chapters includes information about patient rights, so we want anyone involved in the process of patient intake to be involved in that committee, including the front desk personnel and registration department."
2. Compile specific policies and procedures. Committee members at Northwest Michigan take standards established by various accrediting bodies, including the Accreditation Association of Ambulatory Health Care and CMS, discuss exactly how the surgery center will work to meet that standard and publish them in a manual that is kept in a room accessible to any staff member who needs to view it.
3. Assemble the policies and procedures in an organized fashion. Mr. Stilley says the manual containing the surgery center's established policies and procedures is brought together in a very organization fashion. He says every chapter, which tackles each standard one by one, is outlined in the same fashion.
"The policies and procedures are all kept in a three-ring binder," he says. "So any staff member can open to any chapter, such as Chapter 1, Rights of the Patients, and is immediately able to read the exact verbiage of the standard established by an accrediting body."
4. Evidence compliance to standards. One of the challenges of an accreditation survey is the different subjectivities amongst surveyors about how a surgery center achieves compliance to a standard. Mr. Stilley says to combat this, his surgery center evidences compliance directly in the manual.
"If a surveyor asks to be shown how we meet any standard, we can go right down to the exact chapter and subsequent subchapters and say 'Here's 15 ways we are meeting this standard' and then document detailed examples of how we carried those actions out," He says.
5. Provide quick go-to guidelines for staff members. Included in the manual before each chapter are quick go-to guidelines for staff members to read on established policies and procedures. This avoids the need to read through official verbiage and long explanations of policies and procedures in the case a staff member needs a quick overview.
"Each committee has to put together quick bullet points on what the most essential points are about the subsequent topics," Mr. Stilley says. "For example, before the first chapter about patients rights begins, there is a sheet with bullet points asking 'Did you know' questions, including 'Did you know Northwest Surgery Center has a website with information on how to contact the facility and its privacy policies?'"
6. Develop a system of accountability. Since every chapter is put together by a formal committee, Mr. Stilley developed protocol requiring committees to put together a list of names of staff members in the committee and staff members responsible for reviewing the chapters. The review of records build better accountability for those responsible for putting the chapters together and disseminating the knowledge throughout the facility.
Learn more about Northwest Michigan Surgery Center.