In a session at the Becker's ASC 23rd Annual Meeting: The Business and Operations of ASCs, Oct. 27 to Oct. 29 in Chicago, Alicia Johnson, consultant and Accreditation Association for Ambulatory Health Care surveyor with Healthcare Consultants International, discussed common deficiencies cited in AAAHC surveys and how ASC can avoid them.
Here are seven key ways to stay on top of survey preparation and avoid deficiencies:
1. Review personnel files. Review all credentialing and privileging paperwork for your clinical staff and also review personnel files for all new staff members. Sometimes the newest employees have been there two months, but they haven't gone through a proper orientation and their file is empty, noted Ms. Johnson.
Have one person in charge of credentialing, privileging and peer-review. "Make sure this person is detail-oriented and thorough," she added. "We do see some wonderful credentialing files, but more often than not, it is loose papers and a folder. Have a checklist for what needs to be in the credentialing files. Also, providers cannot approve their own privileges. We see that all the time. Send the provider's credentialing file out for peer review."
2. Document center activities and processes. Ms. Johnson suggested ensuring the following are documented and reviewed prior to a survey:
• Governing board minutes
• Quality improvement committee minutes
• Adverse incident reports (anything that is unplanned is an adverse event)
• Quality improvement studies (educate your staff and get them involved)
• Patient satisfaction surveys (not just the scores, but comments as well and how you dealt with it)
• Infection control reports (have a process and document the process you use to track and follow up on postoperative infections)
• Chart audits
• Specimen logs
• Safety checklists
• Inspect and test fire suppression devices
3. Use safe injection practices. Cite the organization whose guidelines you are following in your policy, said Ms. Johnson.
"Also, educate your staff and make sure surveillance is being carries out. How often do you watch each other while performing injection practices? Show this to us. Document the day you do this. For example, the first Monday of every month so-and-so is in charge of conducting surveillance, exposure control plan," she said.
Also keep in mind the appropriate use of single and multi-dose vials. Medical staff cannot bring multi-dose vials into the patient room and staff must draw the injection away in a sterilized space away from the patient.
4. Establish quality improvement processes. Write out your QI program goals and follow them. "Sometimes people just do QI activity without learning from it. If you don't measure a metric and make a change and measure it again, it's not a study," said Ms. Johnson.
Also, some centers don't analyze national benchmarks properly to see where they fall short. "Conduct an annual evaluation," she added. "One out of 20 centers has an annual evaluation."
5. Ensure you have written policies. If you don't have written policies, it is hard to show surveyors how you handle issues in your center. Here are the most common missing written policies, Ms. Johnson noted:
• Resolving patient grievances
• Care of pediatric patients
• Policies for students or trainees
• Method of how and why a patient may be dismissed or refused care
• Impaired healthcare professional or suspected impairment
• Incapacitated healthcare professional
• Recalls
• Medical instruments that fail to meet sterilization guidelines
• Single or multi-dose vial/injectable
• Isolations/transfer of patients with communicable diseases
• Evaluation and management of pain
"Make sure policies for all these situations are written out and you can show them to us," said Ms. Johnson.
6. Don't forget that first impressions are crucial. Surveyors get their first impression from the time they walk up to the door. Make sure there are no dead plants in the waiting room or stains on the carpet.
"When you walk into a center that isn't clean, you don't feel good about the center," said Ms. Johnson. "Patients don't necessarily know what equipment you have and where the doctor completed medical school. But they do know how clean your center is."
7. Conduct a self-test. Look back to your previous surveys to see what comments surveyors made and make sure you have followed up and addressed those comments, said Ms. Johnson. Consult your AAAHC handbook and if there is something you don't understand, call the organization. Also, have your management team sit down with the handbook and look at it together because there may be differences in terms of how your team members understand a certain standard.
"Share the responsibility and get your staff involved," she said. "Test yourself and review, review, review."