Ray Grundman, senior director of external relations for the Accreditation Association of Ambulatory Health Care and an AAAHC surveyor, offers five steps that ambulatory surgery center leaders can put in place at their centers to always be prepared for an accreditation survey.
1. Create a master list. Whether an ambulatory surgery center is a small or large facility, there is such a large number of tasks that need to be accomplished during a day that it is imperative to have everything written down. The best way to keep tasks organized is by cultivating one master list. "I would always recommend that surgery centers create a master list for accreditation, which includes things that need to be checked daily, weekly, monthly, bimonthly, quarterly and yearly," says Mr. Grundman.
The items on this list will be routine, but someone needs to be responsible for ensuring that each item is checked off the list at the proper time. "Ultimately, the responsibility falls to the administrator, but a good administrator has a team approach," says Mr. Grundman.
2. Put in place contingency plans. A contingency plan is key to making certain that the tasks on the surgery center's master list are completed, no matter what situation arises. "You know the unexpected could happen, but it is always a surprise. Be prepared to roll with these kinds of things and get done what needs to be done on a regular basis," says Mr. Grundman.
Though the ASC administrator will primarily be responsible for keeping track of the master list and assigning the tasks on it, it is critical that someone else will be able to fill this administrative role. It is entirely possible that an ASC administrator will become unavailable. "In that case, administrators should leave a road map for someone else to follow in their footsteps," says Mr. Grundman.
In larger surgery centers, there is not one person that is a jack of all trades. On a day to day basis, and especially when the administrator is not there in a directive capacity, the entire ASC team needs to understand who is responsible for what item on the list. If a personnel disaster occurs, there should always be someone prepared to step up and make certain that each task is completed without a hitch.
3. Maintain ongoing staff education and communication. A well-integrated staff is essential to completing the assignments on a surgery center's checklist. Even centers with established contingency plans should make a regular practice of promoting staff communication and interaction. "On both the clinical and business side, the staff must know what needs to be done on a daily basis. It should be an ongoing policy that the staff reviews these things," says Mr. Grundman. "Once or twice a year have your employees spend a day in someone else's job. They need to see the bigger picture. It is good for continuity and morale."
Every time a new protocol or update is made to a surgery center's routine the staff needs to be informed and trained. For example, if there is a computer software update, staff should be trained on the new steps and processes needed to effectively use the program.
"Communication among employees is very important so you don't lose things from one day to the next. This is where supervisors come in. The administrator is the thread of continuity. Administrators need to be kept informed so they can return to the master list and delegate," says Mr. Grundman.
4. Do a daily walkthrough of the center. One of the most effective ways to check if the items on the master list are being completed and the list is up-to-date, is by performing a daily walkthrough of the facility. "At the beginning of the day, everyone should inspect their workspace," says Mr. Grundman. Is the physical environment up-to-date? Is it a safe and sanitary environment? As surgery center leaders ask themselves these questions, they should add anything that needs to be updated on the master checklist.
5. Never delay tasks that could be done today. Avoidance behavior is one of the biggest mistakes that can occur in surgery centers. "Inertia takes effect. If for some reason, you don't have adequate staffing you need to make adjustments, Getting caught up and staying caught up is the hardest thing to do," says Mr. Grundman.
Receiving and storing deliveries is one area in particular that seems to frequently slip through the cracks at surgery centers. Surgery centers receive large amounts of supplies. Some receive smaller, more frequent shipments of supplies, while others take large shipments at regular intervals. Putting these deliveries away in a timely fashion is necessary.
"Patient care comes first, so this can be easy to forget," says Mr. Grundman. "If you have an order in, you need to have an extra person or someone to stay late and put everything away." Deliveries that remain unpacked and outside of the storage area create blocked hallways, which is a fire code issue.
"Surgery center leaders should never lose track of the check list," says Mr. Grundman. An accreditation survey could take place unannounced on any day and the best strategy is to act as if that day is everyday.
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