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SDS Accreditation Update
A surveyor at your door? Senior managers out?
Make sure other managers know how to find info
One of the first steps to take for a successful survey is to make sure that staff members who know the location of all documents needed by the surveyor are at work when the surveyor arrives.
When a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC) arrived at one outpatient surgery center to conduct a survey, she was greeted by a lone receptionist. "She told me that the center had no cases scheduled that day, so she was the only staff person, and she asked me to come back another day," says the surveyor, Betty Bozzuto, RN, MBA, CASC, executive director of Naugatuck Valley Surgical Center in Waterbury, CT. "I explained that the center had been notified that I was surveying the center on that day, so she needed to call some people to come in to work," she says. Two people did come to meet with Bozzuto, but she points out that their initial absence was a good indication of how ill-prepared they were for the survey.
You always must be ready
Although AAAHC does provide exact survey dates for non-Medicare accreditation surveys, Medicare surveys are completely unannounced, says Bozzuto. Just like The Joint Commission's unannounced surveys, organizations can block certain times of the year if there are special events or activities that will interfere with the surveyor's ability to evaluate the program, she says. However, throughout the rest of the year, you always must be ready, Bozzuto says.
Organize your documents
In addition to having a policy that requires the presence of a management team member in the center at all times, it also is important to organize your documentation in notebooks that are clearly labeled and placed together in one location, suggests Ann Purvis, RN, BSN, CNOR, surgical services clinical director and director of nursing at SurgiCenter Services of Pitt in Greenville, SC. Making sure that all levels of management know the location of the notebooks paid off when the surveyor arrived at the time when Purvis, the president of the surgery center, and the quality assurance manager were out of the building at different meetings. "My assistant nursing manager was able to quickly get the books to the surveyors and answer all of the questions," she says.
In addition to organizing information well, Purvis also recommends that outpatient surgery managers involve staff in all areas of survey readiness. "We try to be very transparent in our organization so that everyone knows what is happening in all areas," she says. "This enables any management person from any area to find information and answer questions intelligently."
For more information on handling accreditation surveys when your top management is out, contact: