One of the biggest concerns for ambulatory surgery center operators is Medicare inspections and accreditation survey readiness.
At the Becker's ASC 21st Annual Meeting – The Business and Operations of ASCs, Jan Allison, RN, CHSP, director of accreditation and survey readiness at Surgical Care Affiliates, gave a presentation titled "Medicare Inspections and Survey Readiness." She discussed how the guidelines have changed over the years, with the 2009 revisions and additional updates since then.
"You need to make sure your program covers scope, data, program activities, PI projects and documentation to support the projects," she said. "You have to have proof in the governing body minutes that everything was addressed."
The updates since 2009 include:
• Notice of patient rights — now can be done at the start of the surgical procedure
• Emergency equipment — ASCs must have a list of emergency equipment determined by the governing body
• Physician environment — addressing humidity
• Radiological services — now you don't need a credentialed radiologist on staff, just to identify a qualified person who is responsible for overseeing the services
• Infection control — now flash sterilization is referred to as IUSS
• Advanced directives — the policy should not say the ASC "does not honor"
Ms. Allison also addressed several trends for ASCs, including going beyond hand hygiene in quality improvement projects and continuing to focus on appropriate medication administration. Another huge issue for ASCs is credentialing and competency.
"Just because someone is certified doesn't mean someone is competent," she said. "We can't get comfortable with how things are. We have to make sure we have continuous audits so people are completing their processes appropriately. "
Accreditation standards also very by state, and compliance at the local and national level is crucial for the center.
"The key to success is providing guidance to staff members," Ms. Allison said. "Conduct mock surveys to assess compliance, address issues in a timely fashion and hold people accountable."