Becker's ASC Review

20 EXECUTIVE BRIEFING 1 EXECUTIVE BRIEFING ASCs often seek Joint Commission 1 accreditation to demonstrate their commitment to patient safety and quality care. Earning ambulatory care accreditation builds credibility among patients, payers and network providers and reinforces a culture where continuous quality improvement of day-to-day operations is a top priority. Through its extensive interactions with customers nationwide, Olympus identified key best practices that ASCs have employed when preparing for a Joint Commission audit, as well as potential challenges. To learn more, Becker's ASC Review recently spoke with Melinda Benedict, Director of Infection Prevention & Control at Olympus. The importance of Joint Commission accreditation While accreditation takes time and money, it demonstrates an ASC's dedication to patient safety and quality care. The comprehensive operational policies and procedures required for Joint Commission accreditation help prevent healthcare-associated infections, reduce the risk of bloodborne pathogen exposure and help ensure that medical device reprocessing and sterile processing are done safely and effectively. Accreditation differentiates ASCs in the eyes of patients and payers because this designation is associated with a high standard of care and better outcomes 2 . "When patients see that an ASC is accredited, it means something," Ms. Benedict said. "Consumers are getting more savvy about their health. If you are in an area with a lot of competitive facilities including hospitals, accreditation can help level the playing field for an ASC." Preparing for an audit: Policies, guidelines and documentation It's essential to keep all facility standard operating procedures (SOPs) up to date and easily accessible for staff. When it comes to endoscopes, policies should cover the entire reprocessing cycle, including: • Pre-cleaning • Transport • Manual cleaning • Sterilization • Drying and storage practices • Staff training and competency • Documentation Understanding established guidelines and integrating them with internal policies helps providers align with industry best practices. Examples of these guidelines include the Association for the Advancement of Medical Instrumentation (AAMI), the Society of Gastroenterology Nurses and Associates (SGNA), the Association of Perioperative Registered Nurses (AORN) and the Centers for Disease Control and Prevention (CDC). "I think a key consideration with endoscope reprocessing, especially for ASCs that are just starting out and don't yet have tenured staff, is how to build best practice guidelines into internal policies," Ms. Benedict said. "That's where cross-referencing guidelines and standards becomes important – so facilities can integrate that information into their procedures." It's important to thoroughly document all relevant procedure and reprocessing activities, so it's possible for an auditor to "trace an endoscope" by serial number all the way from the start of a procedure through reprocessing and its placement back in storage. The data that should be documented to support traceability may include the patient ID, physician ID, procedure date and time, reprocessing technician's ID, reprocessing logs, automated endoscope reprocessor serial number, scope serial number and chemical lot numbers. Ms. Benedict added that traceability can be a valuable tool in audits, as it helps uncover potential gaps that may exist in a workflow process and documentation. Using reprocessing equipment that automatically records data can make the documentation process easier to manage. For example, the OER-Elite™ Endoscope Reprocessor 3 maintains records for every scope that is reprocessed. It also records detergent and disinfectant replacements, as well as filter changes. Data can be exported from the reprocessor for easy analysis and viewing if the Joint Commission auditor requests records. Adherence to internal infection prevention protocols is also critical. These may include rules on hand hygiene, PPE adherence, standard practices for handling biohazard waste and more. Preparing for a Joint Commission audit Documentation and traceability are often challenging areas for ASCs during a Joint Commission audit. Missing or outdated documentation is problematic. Examples include incomplete reprocessing logs or serial numbers that have not been recorded. Facilities should also keep instructions for use (IFUs), SOPs and other important reprocessing documents readily available. "You don't want to be in a panic trying to 'fix' everything the moment that you learn that the Joint Commission is in the area," Ms. Benedict advised. "In addition, if you just try to put a band-aid over things to pass the inspection, your facility isn't getting the true benefit of the accreditation process, which is improved patient safety and a mindset of continuous improvement." Staying audit-ready: Best practices for Joint Commission Accreditation in ASCs 1 https://www.jointcommission.org/what-we-offer/accreditation/ 2 https://manual.jointcommission.org/Accreditation/WebHome 3 https://medical.olympusamerica.com/oer-elite

• Cover