What do you do to plan for initial or recertification? Can you discuss and maybe key areas you focus on and how much time you allocate to those?
Regina Robinson, administrator of the Toledo (Ohio) Clinic — Outpatient Surgery: The one thing that can probably trip you up the easiest is when they do tracers, following patients from admission to discharge. They’ll hit all areas [of the patient’s experience], so it’s a challenge. Have mock audits, perhaps, or at every staff meeting have a topic you’ll discuss. I’ve actually had mock surveyors come in, which is helpful. We always work toward a state of readiness. Keep track of infection rates and make it part of monthly staff meetings. Keep the staff directly involved.
Marti Potter, administrator with Jersey Shore Ambulatory Surgery Center in Somers Point, N.J.: Most surveyors do come in and speak to staff. Staff needs to know not to b-s them. The surveyor knows right away if a person is involved [in compliance], or if they’re making it up as they go. [If they’re asked a question they don’t know the answer to,] all staff need to say is they’re not sure but they know where to find the answer. It’s also important to make sure you have physician involvement. Surveyors also want to speak to your docs, especially as they do a tracer. You want to make sure physicians have the basic answers.
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