6 Tips to Breeze Through Your Next Surgery Center Accreditation

1. Clear documentation for infection control. Infection control meetings address quality infection control topics such as sterilization techniques, hand washing, postoperative infections, protocols for needle sticks and cleaning processes. Require all clinical staff members attend and document the meeting minutes, said David C. Watts, MD, the Vice President of Education for the American Association for Accreditation of Ambulatory Surgery Facilities.

"The meeting minutes have to chronicle exactly what was said and gone over. If there are any problems, you should document what the plan of action is and how you plan to correct it," he said.

2. A staff focused on accreditation. For ambulatory service centers going through the survey for the first time, the obvious focus is to gain accreditation. However, for centers that are already accredited, Gina Dolsen, RN, BSN, MA, vice president of operations for Blue Chip Surgical Center Partners and an Accreditation Association for Ambulatory Health Care surveyor, said to make the survey work in the ASC's favor.

She recommended driving the surveyors to where the center needs help and to use the AAAHC to the center's advantage. "A survey can be to your benefit; it doesn't have to mean your demise," Ms. Dolsen said.

Additionally, ASCs should focus on topics that have been in the news leading up to the survey date. "If it has been in the news, it will be on the survey," she said.

3. Wrong site surgery prevention policies. 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, said Donna Tiberi, RN, a standards interpretation staff member with the Healthcare Facilities Accreditation Program.

"Sometimes the time out process is being performed, but staff fails to document it, or elements of the time out are missing," she said. "When a surveyor is on site, they will review charts to verify that time-out was documented." 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 said. "You need to follow consistent policies, and procedures."

4. Smooth care transitions between providers. Although a smooth transition of care between the ASC and other providers is not commonly surveyed by accrediting organizations, this may be something that accrediting bodies move toward surveying in the future.

"Going forward, we will be starting to look at communication between providers and the transition of care," said Susan Lautner, RN, BSN, MSHL, an accreditation specialist for quality and patient safety at the Healthcare Facilities Accreditation Program. "[HFAP] is currently emphasizing this for hospitals but we eventually want to carry that same thread of continuity of care to all facilities."

5. Proper quality assurance programs. One of the most common mistakes Dr. Watts has seen as an inspector is the lack of an adequate quality assurance program in surgical facilities. "You want to look at how you're logging in and tracking narcotics, handling disciplinary problems, the advanced directives looked at by patients, the bill of rights looked at by patients — this has to happen on a daily basis for every case," he said. "You want to make sure that documents like pathology reports and X-rays are being signed off on by the physician doing the case. All of this has to be checked."

6. Updated past policies. If at all possible, with permission from the appropriate personnel, surgery centers should use policies and procedures from previous workplaces as a template. By using policies and procedures from her previous hospital employer, Freida Toler, administrator at Amarillo (Texas) Endoscopy Center, saved time and energy needed to build policies from scratch and helped her facility more quickly achieve accreditation by the AAAHC.

"With permission from the hospital where I was the manager of the endoscopy lab, I brought over the policies and procedures that were used there and revamped them to fit the needs of our endoscopy center," she said. "It required some changing because hospitals run in a completely different manner than ASCs."

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William W. Backus Hospital Earns Blue Distinction


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