Not much has changed over the past year regarding accreditation standards. However, ASCs should constantly think about how their center can continue to improve quality. "In 2010, a lot of changes came through regarding the accreditation process and since then we've been working on refining the processes," says Carla M. Shehata, RN, BSN, Vice President, Operations for Regent Surgical Health. "Now the surveyors are really focusing on the governing board, quality improvement and infection control, and everything else folds into those areas."
Here are six ways to make sure you are ready to ace the accreditation survey.
1. Make sure the governing board is involved in ASC operations. The governing board is often more focused on the ASC's financials, but they must also have a hand in the daily operations. Board meeting minutes should reflect their involvement in creating policies and procedures, annual contract reviews and reconciliation of problems within the center.
"They must be involved in the patient care polices, quality and outcomes," says Ms. Shehata. "They should also help develop processes and be supportive of following them. There are many ways to meet the accreditation standards, and they need to be part of the brainstorming process for how that can best happen within their ASC."
2. Document infection control processes and compliance. The infection control standards have become fairly uniform for Medicare, AAAHC and Joint Commission over the past few years. ASCs are required to have documentation that supports regulation and standard compliance.
"ASCs should follow the new CMS infection control worksheet and be sure to go through any quality improvements with the governing board," says Ms. Shehata. "One problem ASCs have is they do things according to the standards, but don't have any proof. There must be documentation that they can show surveyors; they can't just say they are compliant they have to prove they are."
ASC leaders are responsible for sharing the infection control processes and any changes with all participants. This should be documented in staff meeting minutes, Medical Executive Meeting (MEC) and Governing Board meeting minutes. They can also devise documents and checklists to ensure staff members are meeting the requirements.
3. Conduct facility-wide audits. Continuously conduct facility compliance audits so you know your center will be prepared when the surveyor arrives. AAAHC and Joint Commission have worksheets for ASCs to follow for these audits. Keep your facility compliance audits and use them to show ongoing quality improvement. Be sure to document the action plan when non-compliance is found.
"At Regent, we do 13 intensive reviews per year so we make sure the facilities are ready for surveyors at all times," says Ms. Shehata. "I would strongly suggest looking through any accrediting program's systems and standards, especially if they don't have a check-off sheet for survey readiness. Go standard by standard to make sure you are following all regulations and document how the regulations are met."
ASCs can also hire an outside survey consultant to work with them on compliance. While this person is often expensive, it can be beneficial for a fresh pair of eyes to examine the ASC.
4. Make sure performance improvement projects are meaningful. ASCs are required to undertake quality and performance improvement projects on a regular basis. These projects should be meaningful and have a positive impact on patient care at the ASC, not just thrown together to meet the requirement.
"Performance improvement projects should demonstrate an improvement in quality of care or cost containment," says Ms. Shehata. "Doing a quality improvement project just for the sake of doing it doesn't help anyone. The project should also be well documented and follow a specific format such as the AAAHC 10 Step Process or P.D.C.A (Plan, Do, Check, Act) and repeat if necessary until the goal set has been met. Report any findings to the governing board."
5. Save quality improvement project reports. Record all quality improvement projects and save the findings in your ASC's files. The surveyor will want evidence of the report's completion to make sure all problems were addressed.
"Quality improvement studies should be conducted when a problem is identified. It's important to dig to the root cause and make sure it is corrected," says Ms. Shehata. "The findings must be reported to the Governing Body. Be sure to keep your data as evidence that proves this is a meaningful project. Never write a report and get rid of the data; the surveyors want to see the data and make sure it's actual and pertinent."
There have been some instances where surgery centers devise fake reports just to have them on the books. This doesn't comply with standards and won't help the ASC in the long run.
6. Involve everyone in quality improvement. All staff members at the ASC should understand their role in quality control and become involved in improvement initiatives. Everyone should know the rules in the facility and be encouraged to speak up when the rules are broken.
"The QI facility committee should bring projects together and report the data," says Ms. Shehata. "They should go over changes in policy and make sure their processes match the standards and/or regulations and it is actually what is happening within the center. It's important that everyone feels like they have a hand in it."
ASCs can make data gathering easier by automating their processes. Build a file on your computer system showing QI reports and data. These automated copies are sufficient and convenient evidence for the surveyor as well.
7. Always be survey-ready. ASCs should always be prepared for the survey, but if you know it's coming make sure data is updated well in advance. "A lot of centers try to do these six to eight months before the survey date and they get into a mad frenzy to become survey-ready," says Ms. Shehata. "If they have a program within their center where the areas we have just discussed are in place and are doing these things on a continuum, survey preparedness wouldn't cause such a panic.
Stay informed and stay prepared on a daily basis. Don't just change the standards for the survey; live it."
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