Becker's ASC Review

21 EXECUTIVE BRIEFING To address these challenges, it can be helpful for an ASC to designate a person or a team as responsible for keeping the organization in a continuous audit-ready state. One effective strategy to prepare for a Joint Commission visit is to perform periodic surprise internal self- audits. This is a way to proactively identify potential problem areas and resolve them. "It's so much easier if you have someone who is on top of audit readiness all year round," Ms. Benedict said. "Not only does it make the inspection easier, but it also encourages the facility to utilize the Joint Commission audit process in the way it's intended, which is for continuous improvement." Establishing audit-compliant reprocessing rooms In ASCs, the space available for endoscope reprocessing rooms is often limited. Even small reprocessing rooms, however, can still be compliant with Joint Commission audit requirements. One of the most important things to consider is whether the reprocessing area will allow staff to comply with the processes outlined in the manufacturer IFUs. "When the IFU outlines a required step, it has been validated and should be followed. If adhering to the instructions isn't feasible, it's important to find an appropriate solution," Ms. Benedict said. Incorporating an appropriate standard or guideline for endoscope reprocessing (e.g., AAMI, SGNA, AORN, CDC, etc.) provides additional guidance, over and above what's contained in the device IFUs. Examples include staff training and competency recommendations, ergonomics, ensuring the appropriate unidirectional flow of devices during reprocessing and logistical considerations for reprocessing spaces. Tips for maintaining continuous audit readiness One thing to keep in mind is that Joint Commission inspectors often hold a pre-meeting with staff who will be assisting with the audit. This provides an opportunity to ask questions before they get started. Typically, there is also potential for an exit interview at the conclusion of the audit to discuss any of the findings and question their findings as needed. If an organization disagrees, they should provide clarification and supporting evidence, such as IFUs, official communications from the manufacturer like field corrective actions, or standards and guidelines, according to Ms. Benedict. If the findings are upheld even after discussing them with the inspectors, follow The Joint Commission's established escalation process. This may offer additional opportunities to provide more in- depth evidence of your organization's compliance. Ideally, ASCs should adopt a proactive stance toward being audit ready. This means following processes consistently and ensuring documentation is complete and easy to find. As guidelines change, these should be incorporated into internal policies and procedures. It's also essential to stay current on employee education. For ASCs with an Olympus service contract, Endoscopy Support Specialist team members are available to come onsite to train staff on how to reprocess scopes in accordance with Olympus IFUs. "The Endoscopy Support Specialists can come in, look at what you're currently doing and identify areas for improvement," Ms. Benedict said. "You can use that experience to help make sure you're adherent to the IFUs, which is something that Joint Commission inspectors are looking for." Olympus' professional education website 4 offers webinars on reprocessing and infection prevention, and many of these sessions give participants continuing education credits. Additionally, educational resources specific to infection prevention and control in endoscope processing are available in multiple languages on Olympus' global Infection Prevention and Control webpage 5 . ASCs have a proven track record of providing excellent patient care and outcomes at a lower cost than other healthcare facilities 6 , and Joint Commission accreditation is one way to formally recognize an ASC's focus on quality and patient safety. "At its core, accreditation is about patient safety," Ms. Benedict said. "You invest in an audit to help ensure your organization is adhering to, or exceeding, current best practices in your clinical area of expertise, confirming that you meet the same high standards as other accredited ASCs." At Olympus, we are committed to Our Purpose of making people's lives healthier, safer, and more fulfilling. As a global medical technology company, we partner with healthcare professionals to provide best-in-class solutions and services for early detection, diagnosis, and minimally invasive treatment, aiming to improve patient outcomes by elevating the standard of care in targeted disease states. For more than 100 years, Olympus has pursued a goal of contributing to society by producing products designed with the purpose of delivering optimal outcomes for its customers around the world. For more information, visit www.olympusamerica.com. LCR55464V01 4 https://www.olympusprofed.com/ 5 https://infectionprevention.olympus.com/en-us/ 6 https://www.ascassociation.org/asca/medicare/legislative-priorities/quality-access-act?utm

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