CMS' accreditation standards, which other accrediting bodies such as AAAHC adopt, change rather frequently and add new, sweeping measures that are hard to meet. Many ASCs, for example, found the new conditions of coverage, such as new infection control measures, released in 2009 to be particularly difficult and hard to interpret. Terri Lopez, administrator at Gulf Coast Endoscopy Center of Venice (Fla.), shares the challenges her own ASC faced and how it overcame them.
Q: What was one of the challenges you faced in terms of retaining your accreditation status?
Terri Lopez: With our last survey in 2008, our ASC had an arrangement with a management company, and at that time the conditions of coverage were not released yet. The challenge as we get ready for our next accreditation is that because we are freestanding and no longer under a management company, we were trying to find the time to pull the necessary information and be prepared to meet the new standards. It's hard finding the time because most of our nurses and the management team are actually in the trenches. I'm sure most small ASCs have this same problem.
Q: How did Gulf Coast Endoscopy work to find the time for survey preparation?
TL: We basically prepared for the new standards by pulling the current requirements through AAAHC, which the ASC management team then divided among the members and created teams for some areas. Certain staff members were responsible for certain pieces. For example, our infection control specialist would take the infection control piece. We created a new quality team, and that team pulled information on quality improvement together and developed a much better quality program than we had in the past.
Q: A new aspect of the 2009 conditions of coverage included increased infection control measures. How did Gulf Coast Endoscopy tackle this?
TL: Our ASC installed some foam hand sanitizers throughout the ASC and by every bedside. We also found, in addition to staff members, patients and family members were also using them. Our infection control committee makes sure policies are updated in accordance with what the standards call for and assures the training of the staff. The committee meets on a quarterly basis and performs monthly surveillance to ensure infection control compliance.
Learn more about Gulf Coast Endoscopy Center of Venice.
Q: What was one of the challenges you faced in terms of retaining your accreditation status?
Terri Lopez: With our last survey in 2008, our ASC had an arrangement with a management company, and at that time the conditions of coverage were not released yet. The challenge as we get ready for our next accreditation is that because we are freestanding and no longer under a management company, we were trying to find the time to pull the necessary information and be prepared to meet the new standards. It's hard finding the time because most of our nurses and the management team are actually in the trenches. I'm sure most small ASCs have this same problem.
Q: How did Gulf Coast Endoscopy work to find the time for survey preparation?
TL: We basically prepared for the new standards by pulling the current requirements through AAAHC, which the ASC management team then divided among the members and created teams for some areas. Certain staff members were responsible for certain pieces. For example, our infection control specialist would take the infection control piece. We created a new quality team, and that team pulled information on quality improvement together and developed a much better quality program than we had in the past.
Q: A new aspect of the 2009 conditions of coverage included increased infection control measures. How did Gulf Coast Endoscopy tackle this?
TL: Our ASC installed some foam hand sanitizers throughout the ASC and by every bedside. We also found, in addition to staff members, patients and family members were also using them. Our infection control committee makes sure policies are updated in accordance with what the standards call for and assures the training of the staff. The committee meets on a quarterly basis and performs monthly surveillance to ensure infection control compliance.
Learn more about Gulf Coast Endoscopy Center of Venice.