At the 20th Annual Surgery Centers Conference on Oct. 25, administrator Wendy Kelley, CASC, and clinical director P.J. Jarboe, RN, shared inside tips on preparing for Joint Commission accreditation surveys at surgery centers.
Ms. Kelley and Ms. Jarboe lead Cool Springs Surgery Center in Franklin, Tenn. The multispecialty surgery center earned Joint Commission accreditation in 2010 and 2013 with zero deficiencies. "Achieving Joint Commission accreditation means you have a high standard for patient care and safety. The best way to pass a survey is to be prepared," said Ms. Kelley.
1. Leadership involvement. Successful accreditation involves a center's entire staff, but it begins with the ASCs leaders. "The governing board should be involved in all aspects of your facility's operations," said Ms. Kelley. At Cool Springs Surgery Center, each section of the Joint Commission standards was assigned to a staff member. Ms. Kelley and Ms. Jarboe set aside an hour or two each week to review each chapter. Each standard was read and discussed. "Be prepared to cite policy and support your position," said Ms. Kelley
2. Documentation. During the study and review the Joint Commission standards, check what documents will be required. Read the Joint Commission Activity Guide for a comprehensive list of documents. Prior to the survey, have each and every document ready for the surveyor. "The more organized you are, the less they seek out issues," said Ms. Jarboe. Preparation and meticulous documentation indicate a compliant center.
3. Create a schedule. Preparation for an accreditation survey should begin well before the survey date. "It can be overwhelming to keep up with dates and deadlines. Checklists are key," said Ms. Kelley Involve both the business and clinical staff in the preparation process. The schedule will not only include preparation for accreditation every three years, but yearly self-assessments as well.
Review every single standard annually and conduct follow-up audits for problem areas. Full readiness surveys completed every six months will also be a vital part of an effective schedule. Strict adherence to the schedule helps a surgery center to manage the time consuming nature of accreditation preparation.
4. Effective communication. An open line of communication between all ASC team members streamlines the entire process of preparation and the actual survey. Everyone should be prepared to answer the surveyor's questions. In addition, a record of all leadership communication should be kept. "Communication between the PI committee, medical advisory board and governing board should be well documented," said Ms. Kelley. Surveyors will want to see evidence of this communication.
5. Continually provide staff education. There are instructions for use on every item in a surgery center. Encourage every staff member to read and adhere to these instructions. Engage staff members and ask if they have any questions. Hold regular staff meetings. "Things don't stay fixed," said Ms. Jarboe. A well-crafted schedule will include time to reinforce compliance with all standards.