Whether you're a new surgery center looking to receive accreditation for the first time or a seasoned ASC heading towards re-accreditation, the surveying process can be a stressful one. Sandy Berreth, administrator of Brainerd Lakes Surgery Center in Baxter, Minn., and AAAHC surveyor, gives advice on steps you can take a year, six months, a month and a day before your survey, and what to do the day of the survey, to achieve the best possible results.
One year before survey date:
1. Meet with your governing board. In many circumstances, your path toward accreditation will begin with a meeting with your governing board. There, you can get everyone on the same page about your intent to be surveyed and talk about any weak areas in your ASC and how you plan to address them over the next year.
2. Research your accreditation organization's standards. Every accreditation organization will have slightly different standards, and Ms. Berreth says thorough research is essential. "No matter what your accrediting body is, you have to find out their guidelines and do your due diligence," she says. "Many accrediting bodies put out guides or hold workshops, and it's in your best interest to purchase those guides and send a member of your ASC to those workshops and really shape up your ASC with the information you gather." Don't wait until the week before your survey to find out you're not meeting accreditation standards. The day your board decides to pursue accreditation for your ASC, go online and start researching the rules.
3. Start your application. Don't underestimate the time it will take you to fill out the survey application, Ms. Berreth says. "It's relatively easy now, and many accreditation bodies have everything online, but it still takes a while to dot your i's and cross your t's," she says. Whether you're submitting your application online or through the mail, start working on it immediately so you can be ready to submit by six months prior to your survey date.
Six months before survey date:
1. Submit your application. Your application for accreditation will most likely be due at least six months before your survey date. Once you submit your application, the accreditation organization will contact you to say they have received your application and will plan to survey your center. If you are electing a "deemed status" survey, you will not know the exact date of your survey. Instead, the accreditation organization will ask you to provide a 90-day period during which time you could be surveyed on any day. If you are electing a regular survey, you will be given a scheduled survey date.
2. Put your processes through your governing board. In the six months before your survey, make sure your governing board is responsible for the organization of the surgery center and knows about every process you do. For example, if you decide to bring in a company to clean your ASC, you should go through your governing board and let them know your plan. "You need to be diligent about putting every process in your governing board meeting notes," Ms. Berreth says. "You can't do that a week before your survey. You want to show that note-taking is the standard for your organization and that your governing board is actively participating in the management of your surgery center."
One month before survey date:
1. Get your documents in order. In the month before your 90-day survey period begins, you should organize all your documentation. "Surveyors will be blown away if you do this," Ms. Berreth says. "You want quality together, infection control together, board minutes together, committee minutes together." If your policies and procedures are documented online, make sure they are organized and easily accessible for a surveyor. If your policies and procedures are documented on paper, make sure they're organized into categories and nicely bound so your center looks professional.
2. Prepare your staff. Make sure your staff knows the surveyors could walk in at any time — or, if you're opting for a pre-scheduled survey date, make sure your staff knows the exact date and is preparing for it. "Make sure all your staff education is documented," she says. "Go over policies and processes with your staff, and make sure everyone is on the same page and involved in the running of your surgery center." Go through the standards with your administrative and staff team and make sure you're ready for them, so you have time to pick up any slack before your survey date arrives.
The day before your survey date:
1. Prepare your center for the surveyor. If you know your survey date, take some time to prepare your center for the surveyor. If your survey could happen any day in a 90-day period, you should still prepare your center for the first possible survey date by setting up a space that can be easily transitioned into a surveyor workroom. Set up a room where the surveyor can work alone. Don't put the surveyor in your office, where you will be in each other's way and you'll find it harder to get work done. Make sure the surveyor workroom has a telephone for calls to the accreditor, if needed, to check facts or report back.
2. Prepare a folder of information about your center. You can make your life easier by putting all necessary paperwork in a folder you can present to the surveyor when he or she arrives. You can also include a brochure, the welcome sheets you give to your patients and any other information that represents your center.
Survey date:
1. Pay attention to the agenda. Your surveyor will give you an agenda for the survey process, so look at it carefully. "Make sure you know what the surveyor is doing all the time," Ms. Berreth says. "The agenda will say the surveyor is going to tour the surgery center, so make sure you plan a very exact time to do that." The more information you know up front, the fewer questions you will have to ask, and the smoother your process will be.
2. Take care of the surveyor. Don't go overboard with treats and favors, but make sure you offer your surveyor coffee or soda and let him or her know the location of the bathroom and the workspace, Ms. Berreth says.
3. Stay calm. Above all, Ms. Berreth says, understand your surveyor isn't looking to catch you doing something wrong or fail your center deliberately. "As I surveyor, I walk in and I say, 'You know what, we're here to help you, and if we find something wrong, we're going to help you get through the process'," Ms. Berreth says. "As an administrator, if you've read those standards and you're doing a good job at your center, your surveyor is not going to be judgmental if they find you've missed something." If your surveyor does ask for something you haven't done, just be honest. "Stay calm and tell the truth," Ms. Berreth says. "Just say, 'I didn't know that' because many surveyors will respond, 'Well, why don't we get it changed right now?'"
One year before survey date:
1. Meet with your governing board. In many circumstances, your path toward accreditation will begin with a meeting with your governing board. There, you can get everyone on the same page about your intent to be surveyed and talk about any weak areas in your ASC and how you plan to address them over the next year.
2. Research your accreditation organization's standards. Every accreditation organization will have slightly different standards, and Ms. Berreth says thorough research is essential. "No matter what your accrediting body is, you have to find out their guidelines and do your due diligence," she says. "Many accrediting bodies put out guides or hold workshops, and it's in your best interest to purchase those guides and send a member of your ASC to those workshops and really shape up your ASC with the information you gather." Don't wait until the week before your survey to find out you're not meeting accreditation standards. The day your board decides to pursue accreditation for your ASC, go online and start researching the rules.
3. Start your application. Don't underestimate the time it will take you to fill out the survey application, Ms. Berreth says. "It's relatively easy now, and many accreditation bodies have everything online, but it still takes a while to dot your i's and cross your t's," she says. Whether you're submitting your application online or through the mail, start working on it immediately so you can be ready to submit by six months prior to your survey date.
Six months before survey date:
1. Submit your application. Your application for accreditation will most likely be due at least six months before your survey date. Once you submit your application, the accreditation organization will contact you to say they have received your application and will plan to survey your center. If you are electing a "deemed status" survey, you will not know the exact date of your survey. Instead, the accreditation organization will ask you to provide a 90-day period during which time you could be surveyed on any day. If you are electing a regular survey, you will be given a scheduled survey date.
2. Put your processes through your governing board. In the six months before your survey, make sure your governing board is responsible for the organization of the surgery center and knows about every process you do. For example, if you decide to bring in a company to clean your ASC, you should go through your governing board and let them know your plan. "You need to be diligent about putting every process in your governing board meeting notes," Ms. Berreth says. "You can't do that a week before your survey. You want to show that note-taking is the standard for your organization and that your governing board is actively participating in the management of your surgery center."
One month before survey date:
1. Get your documents in order. In the month before your 90-day survey period begins, you should organize all your documentation. "Surveyors will be blown away if you do this," Ms. Berreth says. "You want quality together, infection control together, board minutes together, committee minutes together." If your policies and procedures are documented online, make sure they are organized and easily accessible for a surveyor. If your policies and procedures are documented on paper, make sure they're organized into categories and nicely bound so your center looks professional.
2. Prepare your staff. Make sure your staff knows the surveyors could walk in at any time — or, if you're opting for a pre-scheduled survey date, make sure your staff knows the exact date and is preparing for it. "Make sure all your staff education is documented," she says. "Go over policies and processes with your staff, and make sure everyone is on the same page and involved in the running of your surgery center." Go through the standards with your administrative and staff team and make sure you're ready for them, so you have time to pick up any slack before your survey date arrives.
The day before your survey date:
1. Prepare your center for the surveyor. If you know your survey date, take some time to prepare your center for the surveyor. If your survey could happen any day in a 90-day period, you should still prepare your center for the first possible survey date by setting up a space that can be easily transitioned into a surveyor workroom. Set up a room where the surveyor can work alone. Don't put the surveyor in your office, where you will be in each other's way and you'll find it harder to get work done. Make sure the surveyor workroom has a telephone for calls to the accreditor, if needed, to check facts or report back.
2. Prepare a folder of information about your center. You can make your life easier by putting all necessary paperwork in a folder you can present to the surveyor when he or she arrives. You can also include a brochure, the welcome sheets you give to your patients and any other information that represents your center.
Survey date:
1. Pay attention to the agenda. Your surveyor will give you an agenda for the survey process, so look at it carefully. "Make sure you know what the surveyor is doing all the time," Ms. Berreth says. "The agenda will say the surveyor is going to tour the surgery center, so make sure you plan a very exact time to do that." The more information you know up front, the fewer questions you will have to ask, and the smoother your process will be.
2. Take care of the surveyor. Don't go overboard with treats and favors, but make sure you offer your surveyor coffee or soda and let him or her know the location of the bathroom and the workspace, Ms. Berreth says.
3. Stay calm. Above all, Ms. Berreth says, understand your surveyor isn't looking to catch you doing something wrong or fail your center deliberately. "As I surveyor, I walk in and I say, 'You know what, we're here to help you, and if we find something wrong, we're going to help you get through the process'," Ms. Berreth says. "As an administrator, if you've read those standards and you're doing a good job at your center, your surveyor is not going to be judgmental if they find you've missed something." If your surveyor does ask for something you haven't done, just be honest. "Stay calm and tell the truth," Ms. Berreth says. "Just say, 'I didn't know that' because many surveyors will respond, 'Well, why don't we get it changed right now?'"