The accreditation process can be stressful, especially if your ASC is going through accreditation for the first time or has to address several areas of non-compliance in the months beforehand. Dawn Q. McLane, regional vice president of operations for Health Inventures, discusses eight ways to prepare for accreditation.
1. Purchase new accreditation standards every year. Preparing for accreditation will be easiest for centers that stay up-to-date on accreditation standards, whether or not the center will be surveyed that year, Ms. McLane says. "If you buy the new book every year, even if it's not an accreditation year for you, you won't have to do as much work to go through your survey because you've done the work every year," she says. "If, [instead], you take a break on non-accreditation years, you're going to have to play catch up and do a lot more work."
She recommends buying the standards published by your chosen accreditation body every year and implementing any changes on an ongoing basis. If your center is already compliant with standards by six months before your survey date, you will have a lot less work to do to get ready.
2. Form a committee responsible for survey preparation. Don't burden one staff member with the process of preparing for an accreditation or try to do it all from the administrator’s office, Ms. McLane says. She adds centers shouldn't assume that preparation will happen without careful planning. Ms. McLane recommends forming a committee or task force to sit down and read through the standards and determine who should take responsibility for implementing the changes. To prepare for the survey date, your center may need to change a few processes — for example, start marking the surgical site or doing time-outs before incisions — that will take some time and coaching.
"The administrator and clinical director can't just sit around a desk and get everything ready for accreditation," she says. "From the executive board down to the housekeepers, everyone has to be involved." She says forming a committee is a good way to involve everyone in the process of preparing for accreditation because each committee member can serve as representation for the key players in your ASC.
3. Give yourself time to prepare. Before you start making changes, plan out how long your ASC will need to make the center compliant to accreditation standards. "Each organization should know how long it takes to get through making a change or implementing a process," Ms. McLane says. "It might take three months to get board approval and another few months to implement that change through training." She says centers that have been keeping up with accreditation standard changes may only need six months, while others may need a year or more to prepare.
Some surveyors may want to see documentation that proves your center has implemented a change or adopted a new protocol, not just a policy that states you plan to perform a certain way, meaning your center will have to start more than a few months in advance to ensure you can make the change and document actual performance. "When an accrediting organization comes in, they look to see you didn't just fix everything a week before the survey," she says. "They want to see you've actually been doing it for a while and you've got the process in place."
4. Involve your staff in the preparation process. According to Ms. McLane, one of the biggest "red flags" for ASC surveyors is evidence of inadequate preparation among the center's staff. "It becomes very obvious very quickly to a surveyor if the staff hasn't been involved in the process, because the staff can't answer questions," she says. "I ask questions of the staff and say, 'Tell me your process for sterilization. How do you know how to properly decontaminate and sterilize (or high level disinfect) the equipment and instrumentation you are responsible for?'," she says.
In order to train your staff consistently, form processes with your accreditation committee and write them down. Once you have written out your processes, train each staff member, making sure that the training and the written policies are the same. Ms. McLane says training doesn't have to mean sending staff members out of the facility — on-site inservices, webinars and accreditation body websites can help train staff without forcing them to miss too much work.
5. Document changes. If your center goes through the accreditation standards and realizes a change needs to be made, document the change carefully so you can present that information to the surveyor, Ms. McLane says. "When people make changes to something because they realize they are not compliant with a required standard, surveyors tend to be more understanding when you can demonstrate that you are in a QI process, even though you may not be able to demonstrate 100 percent compliance with the standard," she says. She recommends doing a quality study as part of the change to assess how the new procedure is affecting your outcomes.
6. Perform a mock survey. A few weeks before your survey date or the beginning of your survey period, take your accreditation standards and walk through the standards with your staff. "If there's a standard that you realize you can't demonstrate, you'll be able to find the last-minute areas that still need attention," Ms. McLane says. The mock survey should also help your staff become more comfortable with the survey process. The survey days will always be somewhat nerve-wracking, but walking through the steps ahead of time should assure your staff and physicians that they are prepared and knowledgeable about the standards.
7. Be ready for the survey on the first day of your window. If your survey is happening at some point during a 90-day window, you should be prepared to be surveyed on the first day of that window, Ms. McLane says. Don't assume that you still have a few days or weeks to prepare: by day one, you should have your policy manual, facility documentation, life safety checks, generator documentation, biomedical checks, contracts binder and financial information available.
You should also make sure to schedule a case every day during your survey window, according to Ms. McLane. The surveyor will need to see a case from admission to discharge, particularly for Medicare surveys. "I've had surveys that did not have cases on the schedule every day, and you end up trying to juggle your survey time with the organization to determine how you're going to accomplish the survey requirements that are dependant on observation of a case," she says.
8. Give the surveyor adequate space and resources. Ms. McLane recommends your center try to allocate space as close to the center as possible for your surveyor. "Some organizations that are really small don't have a lot of space available," she says. "They might put the surveyor two floors away in a doctor's office, and it's not useful to be that far away from the center." She says the space provided to the surveyors needs to be in or immediately adjacent to the center so the surveyors can move back and forth freely.
She says your ASC should also prepare space for the surveyors and be prepared to accommodate a surveyor's need to utilize their laptop for documentation during the survey, If possible, be prepared with your WEP key to provide them with internet access.
1. Purchase new accreditation standards every year. Preparing for accreditation will be easiest for centers that stay up-to-date on accreditation standards, whether or not the center will be surveyed that year, Ms. McLane says. "If you buy the new book every year, even if it's not an accreditation year for you, you won't have to do as much work to go through your survey because you've done the work every year," she says. "If, [instead], you take a break on non-accreditation years, you're going to have to play catch up and do a lot more work."
She recommends buying the standards published by your chosen accreditation body every year and implementing any changes on an ongoing basis. If your center is already compliant with standards by six months before your survey date, you will have a lot less work to do to get ready.
2. Form a committee responsible for survey preparation. Don't burden one staff member with the process of preparing for an accreditation or try to do it all from the administrator’s office, Ms. McLane says. She adds centers shouldn't assume that preparation will happen without careful planning. Ms. McLane recommends forming a committee or task force to sit down and read through the standards and determine who should take responsibility for implementing the changes. To prepare for the survey date, your center may need to change a few processes — for example, start marking the surgical site or doing time-outs before incisions — that will take some time and coaching.
"The administrator and clinical director can't just sit around a desk and get everything ready for accreditation," she says. "From the executive board down to the housekeepers, everyone has to be involved." She says forming a committee is a good way to involve everyone in the process of preparing for accreditation because each committee member can serve as representation for the key players in your ASC.
3. Give yourself time to prepare. Before you start making changes, plan out how long your ASC will need to make the center compliant to accreditation standards. "Each organization should know how long it takes to get through making a change or implementing a process," Ms. McLane says. "It might take three months to get board approval and another few months to implement that change through training." She says centers that have been keeping up with accreditation standard changes may only need six months, while others may need a year or more to prepare.
Some surveyors may want to see documentation that proves your center has implemented a change or adopted a new protocol, not just a policy that states you plan to perform a certain way, meaning your center will have to start more than a few months in advance to ensure you can make the change and document actual performance. "When an accrediting organization comes in, they look to see you didn't just fix everything a week before the survey," she says. "They want to see you've actually been doing it for a while and you've got the process in place."
4. Involve your staff in the preparation process. According to Ms. McLane, one of the biggest "red flags" for ASC surveyors is evidence of inadequate preparation among the center's staff. "It becomes very obvious very quickly to a surveyor if the staff hasn't been involved in the process, because the staff can't answer questions," she says. "I ask questions of the staff and say, 'Tell me your process for sterilization. How do you know how to properly decontaminate and sterilize (or high level disinfect) the equipment and instrumentation you are responsible for?'," she says.
In order to train your staff consistently, form processes with your accreditation committee and write them down. Once you have written out your processes, train each staff member, making sure that the training and the written policies are the same. Ms. McLane says training doesn't have to mean sending staff members out of the facility — on-site inservices, webinars and accreditation body websites can help train staff without forcing them to miss too much work.
5. Document changes. If your center goes through the accreditation standards and realizes a change needs to be made, document the change carefully so you can present that information to the surveyor, Ms. McLane says. "When people make changes to something because they realize they are not compliant with a required standard, surveyors tend to be more understanding when you can demonstrate that you are in a QI process, even though you may not be able to demonstrate 100 percent compliance with the standard," she says. She recommends doing a quality study as part of the change to assess how the new procedure is affecting your outcomes.
6. Perform a mock survey. A few weeks before your survey date or the beginning of your survey period, take your accreditation standards and walk through the standards with your staff. "If there's a standard that you realize you can't demonstrate, you'll be able to find the last-minute areas that still need attention," Ms. McLane says. The mock survey should also help your staff become more comfortable with the survey process. The survey days will always be somewhat nerve-wracking, but walking through the steps ahead of time should assure your staff and physicians that they are prepared and knowledgeable about the standards.
7. Be ready for the survey on the first day of your window. If your survey is happening at some point during a 90-day window, you should be prepared to be surveyed on the first day of that window, Ms. McLane says. Don't assume that you still have a few days or weeks to prepare: by day one, you should have your policy manual, facility documentation, life safety checks, generator documentation, biomedical checks, contracts binder and financial information available.
You should also make sure to schedule a case every day during your survey window, according to Ms. McLane. The surveyor will need to see a case from admission to discharge, particularly for Medicare surveys. "I've had surveys that did not have cases on the schedule every day, and you end up trying to juggle your survey time with the organization to determine how you're going to accomplish the survey requirements that are dependant on observation of a case," she says.
8. Give the surveyor adequate space and resources. Ms. McLane recommends your center try to allocate space as close to the center as possible for your surveyor. "Some organizations that are really small don't have a lot of space available," she says. "They might put the surveyor two floors away in a doctor's office, and it's not useful to be that far away from the center." She says the space provided to the surveyors needs to be in or immediately adjacent to the center so the surveyors can move back and forth freely.
She says your ASC should also prepare space for the surveyors and be prepared to accommodate a surveyor's need to utilize their laptop for documentation during the survey, If possible, be prepared with your WEP key to provide them with internet access.