Jennifer Hunara, administrator of the Surgery Center of Allentown (Pa.), manages one of ASCOA's largest and most profitable surgery centers. For three straight years, the center has achieved inspections without a single deficiency with the Pennsylvania Department of Health. Ms. Hunara discusses how her center has maintained its perfect record.
1. Plan for your inspection twice a year. Ms. Hunara's center prepares for its Department of Health inspection in January and again in August. In the facility's first year, staff members had to prepare for the AAAHC accreditation survey in August, and when it came time to prepare for the DOH inspection in January, they found the process was relatively easy because they had already prepared for a survey six months earlier. "We weren't looking at a year's worth of material, and I had touched everything getting prepared for AAAHC," she says. "We said if this worked for us, why don't we treat every August — which is generally our lightest month — like we're having a survey?" It's easier to do the prep work in August, when the center has a light caseload, than it is in January, when volumes are high and the center is financially and operationally closing the year. The center takes some time in August to review contracts, policies and procedures and make sure credentialing and staff files are up-to-snuff.
2. Make inspection requirements a part of daily life. Accreditation and licensure surveyors agree that unprepared employees stick out like a sore thumb in a center under review. If you ignore policies all year and then try to educate staff in the last week before your inspection date, you will encounter high levels of stress and confusion and your employees will forget the information easily. In addition, you will put patients and staff at risk by failing to follow policies that have been mandated for good reason. "We're big on saying, 'If this is a regulation, we have to follow it,'" Ms. Hunara says. The center's managers have monthly checklists that keep them prepared and up-to-date, and staff members are reminded of policies on a regular basis.
3. Quiz employees at your monthly staff meeting. Every month, Ms. Hunara chooses an important infection control topic and discusses it with her employees at the center's staff meeting. "We used to just talk about it, but then we realized that in talking about it, we weren't getting the staff to provide a lot of feedback," she says. "For 2011, when we have a topic, it gets posted the week before and we give them a quiz pertaining to that topic at the meeting. Whoever scores the highest gets a $20 gift card to the coffee shop downstairs, and then we go over the answers and review key points they staff might be asked by a surveyor." The same goes for safety drills: Rather than simply explain what should happen in case of an emergency, Ms. Hunara runs the drills as if an actual incident has occurred. "We try to make them interactive," she says.
4. Build a good relationship with the Department of Health. “Don't be afraid to pick up the phone and call the Department of Health,” Ms. Hunara says. If the center implements a new policy, she and her managers call the DOH to ask if the change meets state requirements. "We just recently adjusted our H&P, and we called the state and asked if the change would be acceptable," she says. She adds that administrators should be polite and flexible during the inspection itself. If a surveyor points out an area of deficiency, don't argue; just explain that you must have missed that particular requirement and ask how the problem can be corrected. Surveyors are often understanding about small mistakes if you show you have made an effort to meet DOH standards.
5. Live in your center the week before the inspection. "Don't resort to sleeping on a stretcher, but make sure you and your managers take preparation seriously," Ms. Hunara says. You should come early and stay late the week before your inspection to make sure you catch and correct any problems. "We really put in the hours to get ready," Ms. Hunara says. "The week before the Department of Health comes in, we don't clock in at 7:00 a.m. and go home at 5:00 p.m. We're here until 11:00 or 12:00 p.m., and we do walk-throughs every other day for two weeks before the inspection."
6. Prep surgeons with annual education and a pre-inspection cram session. Administrators often find it more difficult to prepare surgeons for inspections, as they are busy and may be more reluctant to set aside time for education. To make sure your physicians are ready for the DOH's visit, schedule an annual education session and then follow up with reminders in the last week. Ms. Hunara spends time in the operating room with her surgeons on a regular basis, so she has the opportunity to notice if one physician is breaking protocol.
7. Give immediate feedback after the survey. Give your staff members feedback about the survey as soon as you receive the results. Go over areas of weakness and set goals while the information is still fresh. Ms. Hunara says she winds up the whole process by celebrating with a big lunch for staff, physicians and anesthesia personnel.
Learn more about ASCOA.
Read more about accreditation and infection control:
-Compliance: Do We Want to Get On the Airplane?
-New Jersey Inspectors Find Concerning Violations at Surgery Centers, Surgical Practices
-6 Common Misconceptions About Surgery Center Sterilization
1. Plan for your inspection twice a year. Ms. Hunara's center prepares for its Department of Health inspection in January and again in August. In the facility's first year, staff members had to prepare for the AAAHC accreditation survey in August, and when it came time to prepare for the DOH inspection in January, they found the process was relatively easy because they had already prepared for a survey six months earlier. "We weren't looking at a year's worth of material, and I had touched everything getting prepared for AAAHC," she says. "We said if this worked for us, why don't we treat every August — which is generally our lightest month — like we're having a survey?" It's easier to do the prep work in August, when the center has a light caseload, than it is in January, when volumes are high and the center is financially and operationally closing the year. The center takes some time in August to review contracts, policies and procedures and make sure credentialing and staff files are up-to-snuff.
2. Make inspection requirements a part of daily life. Accreditation and licensure surveyors agree that unprepared employees stick out like a sore thumb in a center under review. If you ignore policies all year and then try to educate staff in the last week before your inspection date, you will encounter high levels of stress and confusion and your employees will forget the information easily. In addition, you will put patients and staff at risk by failing to follow policies that have been mandated for good reason. "We're big on saying, 'If this is a regulation, we have to follow it,'" Ms. Hunara says. The center's managers have monthly checklists that keep them prepared and up-to-date, and staff members are reminded of policies on a regular basis.
3. Quiz employees at your monthly staff meeting. Every month, Ms. Hunara chooses an important infection control topic and discusses it with her employees at the center's staff meeting. "We used to just talk about it, but then we realized that in talking about it, we weren't getting the staff to provide a lot of feedback," she says. "For 2011, when we have a topic, it gets posted the week before and we give them a quiz pertaining to that topic at the meeting. Whoever scores the highest gets a $20 gift card to the coffee shop downstairs, and then we go over the answers and review key points they staff might be asked by a surveyor." The same goes for safety drills: Rather than simply explain what should happen in case of an emergency, Ms. Hunara runs the drills as if an actual incident has occurred. "We try to make them interactive," she says.
4. Build a good relationship with the Department of Health. “Don't be afraid to pick up the phone and call the Department of Health,” Ms. Hunara says. If the center implements a new policy, she and her managers call the DOH to ask if the change meets state requirements. "We just recently adjusted our H&P, and we called the state and asked if the change would be acceptable," she says. She adds that administrators should be polite and flexible during the inspection itself. If a surveyor points out an area of deficiency, don't argue; just explain that you must have missed that particular requirement and ask how the problem can be corrected. Surveyors are often understanding about small mistakes if you show you have made an effort to meet DOH standards.
5. Live in your center the week before the inspection. "Don't resort to sleeping on a stretcher, but make sure you and your managers take preparation seriously," Ms. Hunara says. You should come early and stay late the week before your inspection to make sure you catch and correct any problems. "We really put in the hours to get ready," Ms. Hunara says. "The week before the Department of Health comes in, we don't clock in at 7:00 a.m. and go home at 5:00 p.m. We're here until 11:00 or 12:00 p.m., and we do walk-throughs every other day for two weeks before the inspection."
6. Prep surgeons with annual education and a pre-inspection cram session. Administrators often find it more difficult to prepare surgeons for inspections, as they are busy and may be more reluctant to set aside time for education. To make sure your physicians are ready for the DOH's visit, schedule an annual education session and then follow up with reminders in the last week. Ms. Hunara spends time in the operating room with her surgeons on a regular basis, so she has the opportunity to notice if one physician is breaking protocol.
7. Give immediate feedback after the survey. Give your staff members feedback about the survey as soon as you receive the results. Go over areas of weakness and set goals while the information is still fresh. Ms. Hunara says she winds up the whole process by celebrating with a big lunch for staff, physicians and anesthesia personnel.
Learn more about ASCOA.
Read more about accreditation and infection control:
-Compliance: Do We Want to Get On the Airplane?
-New Jersey Inspectors Find Concerning Violations at Surgery Centers, Surgical Practices
-6 Common Misconceptions About Surgery Center Sterilization