They walk in the door without an appointment. Staff immediately know they are not patients or family members. Within minutes, word has spread throughout your facility – your center is about to undergo an ASC accreditation survey.
Surveys are a fact of life in the ASC industry. Whether they are performed by surveyors from the Centers for Medicare and Medicaid Services (CMS), your state’s department of health, or an accreditation organization, doing well on surveys is critical to your ASC’s success. Poor survey performance can jeopardize your licensure, Medicare certification, and/or accreditation. Lose any of these and you are looking at a loss of insurance contracts and patients.
More importantly, poor survey results may indicate shortcomings that have the potential to jeopardize patient and staff safety. ASC accreditation survey requirements, while they may feel cumbersome, are designed to help support the delivery of safe, high-quality care. By meeting them, you demonstrate a commitment to the wellbeing of everyone served by your ASC.
While your ASC should always strive to meet requirements (more on this later), survey preparation is a worthwhile exercise. Preparation can help shore up deficiencies and ultimately improve survey performance – a win-win combination.
ASC Accreditation Survey Areas of Focus
Here are some areas to focus on prior to an ASC accreditation survey to help improve your likelihood of success.
Policies and procedures. Carefully review your ASC’s policies and procedures. Make sure staff are adhering to them as written. If any policies are outdated, update them. If you have added new policies and/or procedures but lack written documentation, create it.
Physician credentialing. Ensure your physicians are credentialed and their files include all required – and current – documentation. Each physician has numerous documents with expiration dates that differ from physician to physician and document to document. Without careful monitoring, it’s likely one or more of these documents will expire. Expect a surveyor will catch any such lapse.
Personnel records. Keep employee files current and complete. Documents in these files should include job description, competency assessments, training records, performance evaluations and I-9s (used to verify identity and employment authorization).
Decontamination area. Surveyors are paying greater attention to compliance with rules governing sterile processing areas. Under scrutiny is cleaning, disinfection and sterilization of scopes, and separation of clean and sterile processes. Make sure staff follow your policies and procedures and can explain how they adhere to guidelines and manufacturers’ instructions.
Infection prevention. While infection prevention has always been an area of focus for surveyors, it’s receiving even more attention these days. Work with your infection preventionist to ensure staff understand and are following proper processes. For example, if your procedure manual indicates “bonnets over the ears,” then make sure everyone has bonnets over their ears.
Emergency preparedness. Another area likely to face increased surveyor scrutiny during your ASC accreditation survey is emergency preparedness. This issue is in the spotlight thanks, in part, to the CMS Emergency Preparedness requirements that took effect in November 2016. Ensure your ASC has performed its required fire and other emergency/disaster drills and completed the appropriate accompanying documentation.
The basics. Regularly walk around your ASC and look for anything that seems out of place or could jeopardize compliance. Perhaps there’s a cart in the hallway when it should be in a closet. Maybe someone borrowed a policy and procedure binder and did not put it back. Identifying who made the mistake and using the experience as a teaching opportunity helps prevent recurrence of errors.
Perform a visual inspection of your restricted areas, checking for cleanliness. Conduct a “white glove test” on doors, screens, and operating room lights.
Staff preparation. Surveyors will inevitably ask your staff questions during their visit. Prepare your staff for this experience. Ask them questions you think a surveyor might ask. These questions can cover topics such as job responsibilities, policies and procedures, location of equipment, and emergency response.
While staff should be able to answer many such questions, they may not know all the answers. And that’s okay. Rather than make up a response that may be incorrect, instruct staff that it’s acceptable to say they do not know an answer but know where they can find it.
Maintain an ASC Accreditation Survey Mentality
Surveys tend to be infrequent events. This is no excuse for allowing compliance to falter in between surveys. Your staff should approach every day as if an ASC survey may take place.
Here are some quick tips to achieve this mentality:
- Quiz staff. Keep staff on their toes by asking them surveyor-type questions. If someone doesn’t know an answer, you may have identified an area for additional education and/or training.
- Conduct mock surveys. Periodically conduct mock ASC accreditation surveys. A member of your leadership team can fill the role of a surveyor, walking around the ASC and assessing performance. You can also bring in an outside, trained consultant to simulate the survey experience and identify compliance gaps.
- Engage staff. Encourage staff to speak up when they identify potential compliance concerns. Treat these moments as learning opportunities rather than punitive incidents.
- Don’t wait to educate. If you change a process, educate staff on the revision as soon as possible. Remember to update affected policies and procedures as well.
Working to keep compliance on the front of staff’s minds can help your ASC better meet requirements and ensure a consistently high level of care.
Kirk Lagonegro, Director of Operations
