Here are five key points for ASCs to focus on for accreditation in 2017 from the American Association for Accreditation of Ambulatory Surgical Facilities.
1. The most consistent and apparent area for improvement for all provider types is documentation and logging. ASCs are no exception. Providers are typically very good at providing care but sometimes have difficulty providing evidence of required compliant practices. Documentation and logging deficiencies consistently populate the top 10 most cited standards lists.
AAAASF encourages facilities to always maintain operational discipline, attention to detail and focus on the patient. Demonstration of compliance is a critical component of accreditation. Without proper documentation, ASCs often struggle to properly demonstrate compliant practices.
2. Near the end of 2016, the 2012 version of the Life Safety Code went into effect for Medicare ASCs. Therefore, ASCs are seeing the first major changes to their fire protection requirements in quite some time.
The new version does differentiate between the requirements for new and existing facilities; however, even existing ASCs will see some new requirements. It applies only to Medicare ASCs. Medicare ASCs would be well advised to prepare for updates. Visit www.aaaasf.org for more information on the new guidelines.
3. In 2017, every CMS provider type, including ASCs, must meet new emergency preparedness standards. AAAASF will be preparing its implementation of the new requirements in the coming months. In the meantime, providers should go directly to the CMS website to prepare for the regulations.
4. Another common deficiency relates to training records in personnel files, such as universal precautions, hazard safety training, fire extinguishers and more. Many ASCs employ staff members that are also on staff at a nearby hospital. The staff receives the required training to remain on staff at the hospital and often the ASC believes this is sufficient. It is not.
Going forward, facilities should obtain a copy of the training at the local hospital or another provider. It is not necessarily required that the ASC provide its own training, if the staff receives all required courses through the hospital. The ASC may elect to do so, but it is not required. AAAASF’s only requirement is that there is a record of adequate training in the staff members' files.
5. ASCs often rely on their staff's years of experience and expertise to define appropriate infection control techniques. Some ASCs adopt a national standard without documenting the decision. Onsite, a surveyor may find a national society’s protocol in place, or an amalgamation of several national programs. However, there often is no documentation of the consideration and explicit decision-making that resulted in the implementation of the program.
Going forward, facilities should document their evaluation and decision-making process. This citation often goes back to the overarching theme of insufficient documentation. In many cases, a surveyor can see the presence of an infection control guideline but it's not always clear when it was implemented or how the ASC's governing body considered alternatives best suited for that ASC. Similarly, it is inadequate for a facility to note they have never had a problem and are experts in infection control. There must be documentation that the leadership specifically considered national programs.