Preparing for a reaccredidation survey can require a great deal of legwork for surgery centers, as ASC leadership works to ensure all documentation and processes meet or exceed Accreditation Association for Ambulatory Health Care standards. When taking on the director of nursing position at Langhorne, Pa.-based The Ambulatory Surgery Center @ St. Mary's in December 2016, Dominic Vendetta, BSN, RN, had to fine tune many of the ASC's processes so it was sufficiently prepared for the AAAHC reaccredidation survey this past July.
"There were a lot of processes that needed some tweaking [when taking on the role]," Mr. Vendetta notes. "The most important process that needed to be addressed was our 'timeout' process."
With nearly 29 years of healthcare experience and 15 years in leadership roles, Mr. Vendetta joined the ASC's team in a time of transition. The Ambulatory Surgery Center @ St. Mary's also hired a new executive director, Ashley Verbitsky, in April 2016 and sought new leadership due to the retirement of the previous nursing director. With the support of Howard Hammer, DO, president of the ASC's board of managers; Benjamin Chack, DO; medical director; and Ms. Verbitsky, Mr. Vendetta amended many of these issues and successfully prepared The Ambulatory Surgery Center @ St. Mary's for the AAAHC survey.
Here is how he did it.
1. Carefully analyzed the ASC's policies and processes. Mr. Vendetta did a "head-to-toe" assessment of the center's clinical processes to allocate areas of improvement, one of which was an inefficient timeout process. Mr. Vendetta reconstructed the process so timeouts were the main priority for staff by shifting from a templated electronic process back to a manual paper charting.
"The patient verification and timeout processes became a routine which can lead to complacency and mistakes," Mr. Vendetta says.
While there was some initial staff resistance to the new procedure, the change paid off with the surgery center significantly increasing its timeout documentation compliance. In March, the ASC had a 46 percent compliance rate. This figure increased 35 percent through shifting to the manual documentation, with The Ambulatory Surgery Center @ St. Mary's achieving an 81 percent compliance rate in July.
"There was going to be a learning curve. [I told staff] if we are going to build clinical excellence, we need to do that through repetition," Mr. Vendetta says. "It is really no different than an ophthalmologist doing 16 cataract surgeries in a day. You become clinically proficient by doing the same thing over and over again."
2. Better managing the ASC's inventory. When Mr. Vendetta joined the center, he notes the storage of supplies was somewhat "chaotic." To eliminate the chaos and create an organized system, Mr. Vendetta re-organized all the sterile supplies in the ASC and placed items together in a systematic way.
"This has improved the efficiency for our materials staff as well as the surgical technicians who are picking surgical cases for the next day," Mr. Vendetta says. "The team now spends less time completing their tasks because the items were not spread across the ASC."
The organizational process was as simple as purchasing bins, labeling them and placing them in a systematic order that matched the staff's workflow. For six months, Mr. Vendetta and his staff sifted through supplies and medications to ensure they weren't outdated. Mr. Vendetta notes, "the entire staff was very committed to the reaccreditation process; I could not have done it without their help!"
Mr. Vendetta developed an account with a pharmaceutical reverse distributer to help minimize the amount of money that would have normally been wasted on the expired medications. During the first six months of the program, the ASC recouped more than $1,000 from those expired medications. Although the AAAHC surveyor found two expired medications, the surgery center had a "very clean survey" as this was the only clinical deficiency, according to Mr. Vendetta.
3. Assessing all documentation. To prepare for the survey, Ms. Verbitsky and Mr. Vendetta analyzed almost every piece of documentation in the ASC, including policies and procedures, meeting minutes, physician credentialing and staff education records, to ensure every detail was top notch and updated.
"We looked at our clinical staff's files and made sure everything that was " Mr. Vendetta says. "It took a lot of man hours to go through all those files."
The surveyor did indicate some areas for improvement in peer review, which included the ASC enhancing its credentialing process and making sure all physicians who were notified about documentation deficiencies via the peer review committee that had a copy of that letter in their credentialing file. The ASC's credentialing committee will take that under consideration when weighing the decision to reappoint that individual.
"We have been dotting our I's and crossing our T's in [areas] that were missed before," Mr. Vendetta.
The long hours spent preparing for the survey paid off, with the ASC achieving AAAHC reaccredidation for three years. Mr. Vendetta believes having the support of the ASC's board of managers, the medical and Anesthesia directors as well as the staff was a major contributor to this achievement.