Becker's ASC Review

Accreditation & Patient Safety 42 7 Steps for ASCs to Ensure Accreditation Survey Readiness By Laura Miller N ot much has changed over the past year regarding accreditation standards.  However, ASCs should constantly think about how their center can continue to improve quality. "In 2010, a lot of changes came through regarding the accreditation process and since then we've been working on refining the processes," says Carla M. Shehata, RN, BSN, Vice President, Operations for Regent Surgical Health. "Now the surveyors are really focusing on the governing board, quality improvement and infection control, and everything else folds into those areas." Here are six ways to make sure you are ready to ace the accreditation survey. 1. Make sure the governing board is involved in ASC operations. The governing board is often more focused on the ASC's financials, but they must also have a hand in the daily operations. Board meeting minutes should reflect their involvement in creating policies and procedures, annual contract reviews and reconciliation of problems within the center. "They must be involved in the patient care polices, quality and outcomes," says Ms. Shehata. "They should also help develop processes and be supportive of following them. There are many ways to meet the accreditation standards, and they need to be part of the brainstorming process for how that can best happen within their ASC." Carla Shehata 2. Document infection control processes and compliance. The infection control standards have become fairly uniform for Medicare, AAAHC and Joint Commission over the past few years. ASCs are required to have documentation that supports regulation and standard compliance. "ASCs should follow the new CMS infection control worksheet and be sure to go through any quality improvements with the governing board," says Ms. Shehata. "One problem ASCs have is they do things according to the standards, but don't have any proof. There must be documentation that they can show surveyors; they can't just say they are compliant they have to prove they are." ASC leaders are responsible for sharing the infection control processes and any changes with all participants. This should be documented in staff meeting minutes, Medical Executive Meeting (MEC) and Governing Board meeting minutes. They can also devise documents and checklists to ensure staff members are meeting the requirements. 3. Conduct facility-wide audits. Continuously conduct facility compliance audits so you know your center will be prepared when the sur- veyor arrives. AAAHC and Joint Commission have worksheets for ASCs to follow for these audits. Keep your facility compliance audits and use them to show ongoing quality improvement.  Be sure to document the action plan when noncompliance is found. "At Regent, we do 13 intensive reviews per year so we make sure the facilities are ready for surveyors at all times," says Ms. Shehata. "I would strongly suggest looking through any accrediting program's systems and standards, especially if they don't have a check-off sheet for survey readiness. Go standard by standard to make sure you are following all regulations and document how the regulations are met." ASCs can also hire an outside survey consultant to work with them on compliance. While this person is often expensive, it can be beneficial for a fresh pair of eyes to examine the ASC. By outsourcing your billing needs to in2itive Business Solutions, you'll eliminate missed billing opportunities and create a more robust bottom line. Call Jocelyn at in2itive today to learn more. 913.344.7837 www.in2itive.org 4. Make sure performance improvement projects are meaningful. ASCs are required to undertake quality and performance improvement projects on a regular basis. These projects should be meaningful and have a positive impact on patient care at the ASC, not just thrown together to meet the requirement. "Performance improvement projects should demonstrate an improvement in quality of care or cost containment," says Ms. Shehata. "Doing a quality improvement project just for the sake of doing it doesn't help anyone. The project should also be well documented and follow a specific format such as the AAAHC 10 Step Process or P.D.C.A (Plan, Do, Check, Act) and

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