Southgate (Mich.) Surgery Center recently underwent an accreditation survey from AAAHC. Linda Phillips, RN, administrator for Southgate, identifies three areas focused on by the two AAAHC surveyors.
1. Infection control. "They looked at everything," says Ms. Phillips. "They wanted to make sure our documentation was correct. For instance, we do GI cases here. They wanted to see how we knew which scope was used on which patient, how we knew which indicator strips were used in which load. They watched the whole testing process.
"They also spent a great deal of time with our infection control officer, asking her questions, looking at our infection control policies, our OSHA," she says. "They went through employee files to make sure everyone had bloodborne pathogen inservicing. It was all heavily scrutinized."
2. Staff knowledge of policies and procedures. This was the third accreditation survey for Ms. Phillips, and while she expects surveyors to go around and talk to staff, she noticed a much greater emphasis on interviews during this survey.
"They didn't want to know what I say we did all of the time; they wanted to hear it from the people who were in the trenches," she says. "Are we enforcing our policies, are people aware of the policies, are they educated about it, do they do it daily? That was a big focus."
After the surveyors watched a procedure performed, they then followed the staff member who cleans the instruments and talked to her, Ms. Phillips says. "They were interested in observing our routine, our protocol, seeing if we were following the Medicare Conditions for Coverage, the fire and life codes, and making sure we were enforcing and implementing what our policies state."
3. Quality improvement. Ms. Phillips says the surveyors spent significant time looking at the ASC's quality improvement/quality assurance program, focusing in particular on the center's process improvement plans, or "PIPs" as the ASC calls them. A PIP is an aspect of the ASC's operation identified for improvement and how this will be accomplished. For example, one PIP the surveyors focused on at Southgate was centered around handwashing because the ASC gathered a significant amount of data about it.
"It was a pretty intense PIP," says Ms. Phillips. "We were proud of that. [The surveyors] liked it and gave us some ideas of how to make our PIPs better. They felt like we were doing a lot of monitoring but they suggested we increase our time span … to better track and trend."
Learn more about Southgate Surgery Center.
Read more about ASC accreditation:
- 5 Best Practices for Meeting Accreditation Standards
- Meeting Medicare Requirements When ASCs and Practices Share EMR