At the 19th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 25, Beverly Robins, director of accreditation and certification services at Healthcare Facilities Accreditation Program, discusses three key issues related to HFAP accreditation.
Ms. Robbins provided an overview of the accreditation process, which features an unannounced inspection, a physician and/or nurse surveyors, direct observation and review of documents as well as interviews with staff and patients. Surveyors will also follow a patient from admission to discharge and more. Here are three key issues for ASCs to consider:
1. Know the standards. Purchase the HFAP accreditation manual, read and understand every standard, share the standards with employees and understand the scoring. Examples of missed standards include failure to post patient rights, failure to customize purchased policies or failure to document hand hygiene surveillance and environmental rounds.
2. Start on a plan of correction immediately. Ask surveyors questions and for their suggestions to improve processes of care. Include pictures or audits in the plan of correction, when appropriate, and information to demonstrate how sustainability will be achieved.
3. Celebrate. Post your certificate and celebrate your achievement, but ensure ongoing improvement and maintain changes from the plan of correction. Take extra measures to be doubly ready for the next inspection as well, including mock surveys.
Ms. Robbins provided an overview of the accreditation process, which features an unannounced inspection, a physician and/or nurse surveyors, direct observation and review of documents as well as interviews with staff and patients. Surveyors will also follow a patient from admission to discharge and more. Here are three key issues for ASCs to consider:
1. Know the standards. Purchase the HFAP accreditation manual, read and understand every standard, share the standards with employees and understand the scoring. Examples of missed standards include failure to post patient rights, failure to customize purchased policies or failure to document hand hygiene surveillance and environmental rounds.
2. Start on a plan of correction immediately. Ask surveyors questions and for their suggestions to improve processes of care. Include pictures or audits in the plan of correction, when appropriate, and information to demonstrate how sustainability will be achieved.
3. Celebrate. Post your certificate and celebrate your achievement, but ensure ongoing improvement and maintain changes from the plan of correction. Take extra measures to be doubly ready for the next inspection as well, including mock surveys.
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