Nick Marassi, MD, of Kemp Surgery Center in Everett, Wash., discusses how the ASC works to regularly maintain policies and procedures in accordance to Medicare certification.
Q: What processes are in place to help Kemp maintain policies and procedures?
Dr. Nick Marassi: Policies and procedures have to be updated on a regular basis. For our last Medicare certification, the surveyors liked that those policies and procedures were kept updated and organized and that the staff knew them because it's all online so they can click on a policy if they need to review it. Our policies and procedures are updated on a yearly basis. Our system alerts us of when it's been a year since the last review for that policy. You have to spread the policies and procedures out over the year because a facility could have hundreds. So in January, there is a list of policies and procedures that need to be reviewed. Then there will be a new list for February.
When it comes time for review, policies are sent out to staff members in charge of that policy so that they can review it and make any changes or recommendations. Then it's circulated around to other colleagues who may use that policy or procedure. For example, if there's a recovery room policy change, the recovery room charge nurse looks at it first, makes any charges and then passes it onto the quality nurse director and so on until it ultimately goes to the advisory committee. The committee then reviews the changes and signs off on it.
Q: What might cause a change in a policy or procedure?
NM: Practices may change based on changes in the literature, a new study or what someone may have reported at a national meeting about a certain practice. For example, the literature may support a new procedure about a certain pain medication or single-dose vials.
A long time ago, the literature used to say facilities should require patients to urinate before discharging them. Well, the literature has changed, so now we don't require that.
Read more about Kemp Surgery Center.
Q: What processes are in place to help Kemp maintain policies and procedures?
Dr. Nick Marassi: Policies and procedures have to be updated on a regular basis. For our last Medicare certification, the surveyors liked that those policies and procedures were kept updated and organized and that the staff knew them because it's all online so they can click on a policy if they need to review it. Our policies and procedures are updated on a yearly basis. Our system alerts us of when it's been a year since the last review for that policy. You have to spread the policies and procedures out over the year because a facility could have hundreds. So in January, there is a list of policies and procedures that need to be reviewed. Then there will be a new list for February.
When it comes time for review, policies are sent out to staff members in charge of that policy so that they can review it and make any changes or recommendations. Then it's circulated around to other colleagues who may use that policy or procedure. For example, if there's a recovery room policy change, the recovery room charge nurse looks at it first, makes any charges and then passes it onto the quality nurse director and so on until it ultimately goes to the advisory committee. The committee then reviews the changes and signs off on it.
Q: What might cause a change in a policy or procedure?
NM: Practices may change based on changes in the literature, a new study or what someone may have reported at a national meeting about a certain practice. For example, the literature may support a new procedure about a certain pain medication or single-dose vials.
A long time ago, the literature used to say facilities should require patients to urinate before discharging them. Well, the literature has changed, so now we don't require that.
Read more about Kemp Surgery Center.