Administrator Sarah Sterling at Post Street Surgery Center in San Francisco discusses four best practices that have helped the orthopedic-driven surgery center maintain AAAHC accreditation and Medicare certification since it opened in 2001.
1. Stay updated through multiple resources. Various accreditation organizations provide regulations and guidelines for staying accredited. Ms. Sterling says that staying accredited for almost a decade means reaching beyond what's immediately available through accreditation organizations.
"In order to maintaining accreditation, our management staff stays up-to-date on all the current articles when it comes to AAAHC, Medicare, Becker's ASC Review and articles published by other [publications]," she says. "Every year, we also go through our policies and procedures manuals to make sure nothing deviates from those policies."
2. Monitor physicians' and staff performance. A key to maintaining accreditation is to develop accountability throughout the entire facility. Closely monitoring performance of physicians and staff members helps maintain accountability and ensures they are following procedures and protocols properly.
"We have periodic and random audits of policies that are done by the upper management of Post Street Surgery Center to make sure those policies are carried out correctly," Ms. Sterling says.
3. Regularly educate entire staff. Another component to ensuring staff members and physicians are correctly meeting accreditation standards is regular education of the ASC's policies and procedures.
"We have a charge nurse who will select a policy from the center's manual book, and she does morning report about 6:20 in the morning every day where she picks a policy and reviews it with the staff members," Ms. Sterling says. "Staff members then all sign off on it, ensuring that everyone knows the policies. There's so much information, so you want to make sure they're up-to-date."
Post Street also ensures the entire staff is held accountable for continuing education by mailing per diem staff changes in policies. "If that staff member hasn't been here for six months after a few new policies have been implemented, we send those to the nurse or technician and make sure they get confirmation of receipt," she says.
4. Focus on clinical records. Post Street uses electronic medical records for clinical record-keeping, which includes a patient's history and physical information. CMS and AAAHC state these must be kept complete and accurate within 30 days a patient undergoes a procedure. AAAHC cites complete and accurate clinical records as a deficiency most ASCs struggle with. In order to combat this, Post Street makes sure the center's physicians and staff members are adequately trained in using the EMRs.
"We often change the format and content of EMR forms, so whenever we update them, we send those changes to the nurses and anesthesiologists because we'd hate to have them come in and find that the form is changed," Ms. Sterling says.
1. Stay updated through multiple resources. Various accreditation organizations provide regulations and guidelines for staying accredited. Ms. Sterling says that staying accredited for almost a decade means reaching beyond what's immediately available through accreditation organizations.
"In order to maintaining accreditation, our management staff stays up-to-date on all the current articles when it comes to AAAHC, Medicare, Becker's ASC Review and articles published by other [publications]," she says. "Every year, we also go through our policies and procedures manuals to make sure nothing deviates from those policies."
2. Monitor physicians' and staff performance. A key to maintaining accreditation is to develop accountability throughout the entire facility. Closely monitoring performance of physicians and staff members helps maintain accountability and ensures they are following procedures and protocols properly.
"We have periodic and random audits of policies that are done by the upper management of Post Street Surgery Center to make sure those policies are carried out correctly," Ms. Sterling says.
3. Regularly educate entire staff. Another component to ensuring staff members and physicians are correctly meeting accreditation standards is regular education of the ASC's policies and procedures.
"We have a charge nurse who will select a policy from the center's manual book, and she does morning report about 6:20 in the morning every day where she picks a policy and reviews it with the staff members," Ms. Sterling says. "Staff members then all sign off on it, ensuring that everyone knows the policies. There's so much information, so you want to make sure they're up-to-date."
Post Street also ensures the entire staff is held accountable for continuing education by mailing per diem staff changes in policies. "If that staff member hasn't been here for six months after a few new policies have been implemented, we send those to the nurse or technician and make sure they get confirmation of receipt," she says.
4. Focus on clinical records. Post Street uses electronic medical records for clinical record-keeping, which includes a patient's history and physical information. CMS and AAAHC state these must be kept complete and accurate within 30 days a patient undergoes a procedure. AAAHC cites complete and accurate clinical records as a deficiency most ASCs struggle with. In order to combat this, Post Street makes sure the center's physicians and staff members are adequately trained in using the EMRs.
"We often change the format and content of EMR forms, so whenever we update them, we send those changes to the nurses and anesthesiologists because we'd hate to have them come in and find that the form is changed," Ms. Sterling says.