Issue link: https://beckershealthcare.uberflip.com/i/170040
Accreditation & Patient Safety repeat if necessary until the goal set has been met. Report any findings to the governing board." 5. Save quality improvement project reports. Record all quality improvement projects and save the findings in your ASC's files. The surveyor will want evidence of the report's completion to make sure all problems were addressed. "Quality improvement studies should be conducted when a problem is identified. It's important to dig to the root cause and make sure it is corrected," says Ms. Shehata. "The findings must be reported to the Governing Body. Be sure to keep your data as evidence that proves this is a meaningful project. Never write a report and get rid of the data; the surveyors want to see the data and make sure it's actual and pertinent." There have been some instances where surgery centers devise fake reports just to have them on the books. This doesn't comply with standards and won't help the ASC in the long run. 6. Involve everyone in quality improvement. All staff members at the ASC should understand their role in quality control and become involved in improvement initiatives. Everyone should know the rules in the facility and be encouraged to speak up when the rules are broken. "The QI facility committee should bring projects together and report the data," says Ms. Shehata. "They should go over changes in policy and make sure their processes match the standards and/or regulations and it is actually what is happening within the center. It's important that everyone feels like they have a hand in it." 43 ASCs can make data gathering easier by automating their processes. Build a file on your computer system showing QI reports and data. These automated copies are sufficient and convenient evidence for the surveyor as well. 7. Always be survey-ready. ASCs should always be prepared for the survey, but if you know it's coming make sure data is updated well in advance. "A lot of centers try to do these six to eight months before the survey date and they get into a mad frenzy to become survey-ready," says Ms. Shehata. "If they have a program within their center where the areas we have just discussed are in place and are doing these things on a continuum, survey preparedness wouldn't cause such a panic. Stay informed and stay prepared on a daily basis. Don't just change the standards for the survey; live it." n Interested in Reaching Every ASC in the Country? Becker's ASC Review circulates to every surgery center in the United States. Call (800) 417-2035 to discuss 2013 advertising opportunities and partnerships