Common deficiencies AAAASF cites & how to fix them — continuing discussion on keeping up with documentation

For the third installment in this series, The American Association for Accreditation of Ambulatory Surgery Facilities will continue the discussion on the importance of keeping up-to-date records of training and certification that began in an earlier article on Universal Precaution training.

AAAASF Interim COO Thomas Terranova spoke with Becker's ASC Review about common deficiencies related to documentation of annual trainings and certifications.

Thomas Terranova: An overwhelming majority of the top citations relate to documentation of annual trainings and certifications that must be maintained in the employee’s personnel record. Specifically, such ongoing training records include Hazard Safety Training (800.42.10); Basic Cardiopulmonary Life Support (BCLS) or Advanced Cardiopulmonary Life Support (ACLS) certification (800.42.14); Bloodborne Pathogens (800.42.11); Infection Control Techniques (200.55.11); Inoculation or Refusals (800.41.15); health problems which may be hazardous to others (800.40.12); record of continuing education (800.41.14) and other training such as operating a fire extinguisher (800.42.13). Below is additional information on the requirements and importance of each:

  • Hazard safety training should focus on the potential occupational hazards of the facility such as chemical hazards, ergonomic issues (e.g. protecting your back while moving patients), and biological hazards (often covered under Blood Borne Pathogens and Universal Precautions training). The primary goal of hazard safety trainings is to help prevent injuries to workers.
  • BCLS certification is required for all operating room personnel. There must be at least one person in the operating room, and in the clinic whenever patients are present, that holds ACLS certification. CPR certification is not an acceptable substitute.
  • Bloodborne pathogens training safeguards workers against the health hazards that result from exposure to blood and other potentially infectious materials, and aims to reduce their risk from this exposure.
  • Evidence of instruction on infection control techniques should familiarize operating room personnel on the proper techniques to prevent microbial contamination of the sterile environment. This also includes awareness of safe medication preparation and injection practices.
  • Inoculations, refusals, as well as any health problems which may be hazardous to other employees or patients must be identified in the personnel records. Many facilities adopt a policy to collect annual physicals for all employees. This assessment is primarily concerned with the potential risk to patients and other employees of exposure to communicable diseases.
  • Evidence of continuing education is required for all operating room personnel. If the licensing state requires completion of CEU’s or CME’s prior to renewing a medical or nursing license, the current license is acceptable evidence of ongoing education.
  • Other training, such as operating a fire extinguisher, must also be evident in the personnel files. In case of an emergent situation, all operating room personnel must know how to operate a fire extinguisher and any other emergency equipment that may be available to the team. This includes specialized equipment such as equipment designed to respond to unique hazards created by certain chemicals, compounds or dangerous materials.

To maintain compliance, all OR personnel records must show evidence of valid, timely training for each area discussed above. Additionally, the records should contain documentation of inoculation or refusals, health problems, which may be hazardous to others and continued education. When evaluating training and certifications, always consider the specific patient population treated in the clinic as well as the nature of the services provided. For example, training should address pediatric or geriatric specific risks if those populations are treated in the facility. Training should also address exposure risks for radiologic material or other risks specific to the operation of that facility, if appropriate.

The importance of personnel file documentation cannot be overstated. Often, some personnel files are adequate but others are not. Upon hire, facilities should collect evidence of current training.  If the employee does not have training, the facility may hold an inservice prior to allowing the employee to report to work. Online training is often a good alternative to face to face education.

An annual review of the personnel files is necessary to ensure training is current and applicable to the existing standards related to personnel records. Consider a complete review of personnel files prior to a survey to ensure all required elements are accounted for. Evidence of training should be current, within the last year. Facilities must be aware of staff turnover and staff whose training expires at different times of the year.

When it comes to the medical staff, facilities that are deficient are often cited because they believe the physicians’ status on staff at a hospital implies they have received training in the areas discussed here, have been adequately inoculated and have received sufficient continuing education. While this may be true, hospital privileges do not constitute adequate documentation for the purposes of accreditation. The facility must maintain its own record of training, communicable disease controls, and education in its personnel files.

Additionally, per diem nursing staff and itinerant anesthesia must have adequate documentation in all the areas discussed here, either proven out by the service contract or as part of the file they bring when they come to a site to provide care.

Collecting the documentation in advance of the survey facilitates successful completion of your survey and will eliminate many common deficiencies.

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