Accreditation surveys can feel like an us-versus-them scenario, but by preparing amply beforehand and reframing the thought process around surveys, ASCs can be successful in the surveying process.
How to approach an accreditation survey was the topic of a May 6 webinar, hosted by Becker's ASC Review and sponsored by Innovative Sterilization Technologies, featuring Innovative Sterilization Technologies' Vice President of Clinical Services and former accreditation organization surveyor Barbara Ann Harmer, MHA, BSN, RN.
Why get surveyed?
Accreditation surveys are used to show a surgery center is committed to providing care at high levels of quality and patient safety, while operating in a fiscally responsible manner. The surveys are quintessential to third-party reimbursement and organizations are visited regularly by an accreditation company, state health department responsible for licensure and/or CMS.
State departments, accreditation agencies and CMS have their own guidance around quality-measures and infection control, and while the survey process can feel very personal, Ms. Harmer said, surveyors and surveys exist to help centers maximize their potential.
There are many accreditation organizations in the U.S. like The Joint Commission, The Accreditation Association for Ambulatory Healthcare, the American Association for Accreditation of Ambulatory Surgery Facilities and DNV Healthcare. While surveys are no longer voluntary, centers can choose which accrediting body they work with.
Although all accreditation organizations are similar, one thing to note is the hierarchy of standards. Standards can vary between CMS, state and the accreditation organization; and a center's policy must adhere to the strictest standard in the hierarchy.
"If the state has a requirement with a higher level of compliance than what CMS has, you must follow the state," Ms. Harmer said. "You can't just say you follow Medicare in that regard."
Surveying the surveyor
Surveys exist to apply state guidelines, accreditation organization standards and Medicare-certification conditions of coverage. No two surveyors are the same and Ms. Harmer urged, "surveys are only as good as the surveyor that completes them."
"Surveyors are not created equal," she said. "You may find a surveyor that has no experience in the task or jobs being performed in your department. It would be the rarest of circumstances for a surveyor to know 100 percent of what they're surveying."
Center administrators need to account for this disconnect in a surveyor's knowledgebase. Instead of looking at the surveyor as judge-jury-executioner, administrators and center employees should help the surveyor better understand what's happening in their centers. Surgery center employees are the No. 1 advocate of their center. Just because a surveyor has experience in a facet of healthcare does not mean they understand how an individual center is operating.
"It is your responsibility to be able to explain to any visitor what you do and why you do it," Ms. Harmer said. "Having conversations during a survey is consistent across all brands of accreditation companies and it's very normal for surveyors to talk to staff and ask questions."
It's "fair game" for surveyors to question anyone in a surgery center, and there are three ways for an organization to respond to a surveyor: verbal explanation (for items that are not required to be in writing), written materials and direct observation.
"Know the facts about everything you use in your department," Ms. Harmer said. "Do your homework and apply yourself in your daily routine."
Centers should review and know the ins-and-outs of four key areas: personnel, environmental conditions, adherence to infection control guidelines, and quality control and management. Each area has several metrics that fall under the category, and knowing the fine details of each one can make the difference in a survey.
Approaching surveys with a positive mindset, and a working knowledge base of a surgery center's operations is of the utmost importance.
"The purpose of surveys is to assist organizations in acknowledging what is positive and encouraging improvement on what needs to be revised," Ms. Harmer said. "We all can stand to be educated in our processes and our daily offerings for good safe patient care."
View a copy of this webinar here.
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