The following article is written by Amy Mowles, president and CEO of Mowles Medical Management.
Surveyors have a job to do. Think about what they need to report: interpretation and equivalency through implementation. State regulations are absolute, Medicare Conditions of Participation are indisputable and accreditation is all about standards and the context.
You must bear in mind that your policy and procedures are only as good as their implementation. Surveyors can be very skeptical of what they consider heavy-handed consultants or "canned" information. They want assurance that management, physicians and the staff members who run the facility understand the regulations, provisions and standards and have implemented them appropriately.
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I cannot over emphasize the importance of involving key staff in a consultant's or management company's work. Only by immersing your people in the process of review and customization can we make the policies, procedures, and internal processes your own.
Preparation
The key to success is the clear understanding of the entire staff and management of the state regulations, Medicare Conditions of Participation and accreditation standards and how your policy and procedures integrate those. You must be able to show surveyors how you have taken templates and made them your own by adopting the standard and expanding on it, especially from a clinical standpoint.
For instance, if you say you are going to follow AORN and AORN says a registered nurse must be in the procedure room even if the sedation is a local, then you must follow that. Be careful what you say you will do. Know the regulations, the Conditions of Participation and accreditation standards and live by them.
Everyone will have standard Medicare deficiencies and no, you cannot correct them onsite. What you don't want is a conditional deficiency. Accreditation bodies will not recommend an ASC for participation if they have even one conditional deficiency. Frankly, why would you have one? It should not be rocket science to read the state operation manual and implement all of it.
During the survey
Make your surveyors comfortable. Be pleased to show them your facility and your policies. People respond to warm people. Remember that surveyors do not make decisions; they make recommendations that go committee. They may also be providing what they consider to be consultative comments and that's all it is. Surveyors do make mistakes and you may be right. Politely challenge them if you believe them to be wrong and then move on.
After the survey
Learn from your deficiencies, and edit your policies & procedures, as per surveyors' suggestions and/or corrected as a plan.
Learn more about Mowles Medical Management.
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