SDS Accreditation Update

Patient safety issues need your attention

Surveyors want to see staff follow policies

Involvement of family members in discharge education and use of a comprehensive medication reconciliation form were the reason for two of the compliments paid to the office-based surgery practice of Gary Burton, MD, a plastic surgeon in Bowie, MD.

"We always have family members listen to discharge instructions and give them a chance to ask questions about post-op care," says Marcia Knight, RN, BSN, staff nurse. The surveyor liked the communication between the nurse and the family members and the way everyone had a chance to clarify information, she explains.

Improved communications is just one focus of the National Patient Safety Goals from the Joint Commission on Accreditation of Health Care Organizations, but Knight says her surveyor looked carefully at all safety issues identified in the goals. "The surveyor traced two of our patients throughout their visit and observed the staff performing the timeout prior to the procedure and the verification of patient identity, site, and procedure," she says.

Policies should reflect activities

Performing tasks that meet the intent of the patient safety goals is not enough, points out Knight. "Make sure that your policies describe the patient safety activities," she says.

"When working with a consultant to prepare for the survey, we discovered that we were doing everything that was required, but our policies didn't reflect what we were doing. For example, everyone in the office knew what our fire plan was and where the exits are located, but it was not written as a policy," Burton says. In addition to written policies, there should be diagrams on walls in all occupied areas, including the offices and waiting rooms, that show two evacuations routes out of each area, sources says.

Be careful when developing policies to meet accreditation requirements, suggests Burton. "Set rules that you can live by," he says. "Make sure your policies reflect what you are actually doing because once you state your policy in writing, you need to make sure you do what you say you are doing."

Ongoing, regularly scheduled staff meetings are very important, says Gail Lanter, CPC, administrator of East Cooper Plastic Surgery in Mount Pleasant, SC. With small staffs, some office-based surgery programs don't think that formal staff meetings are necessary, but when preparing for an accreditation survey, it is critical that everyone understand new policies, the reasons for the policies, what to expect when the surveyor visits, and why the program is undergoing this process, Lanter says. "You can also get a lot of good ideas from staff members to ensure a good survey," she adds.

One area that remains a challenge for office-based surgery programs is benchmarking, says Lanter. Accreditation association surveyors recommend using national or regional studies, or reports published in medical journals, to compare an office's data on infection control, post-op infection, or other clinical or financial issues. However, it is difficult to find the information, Lanter says. When physicians at different facilities agree to conduct peer review on each others' cases, they can agree to a standard set of items for data-sharing and benchmarking, as long as it doesn't violate patient confidentiality or antitrust regulations, sources say.

However, it can be difficult to compare your office-based program to a similar program in your area, Lanter adds. "We are in a very competitive market, and I don't see any office-based surgery programs in the area that want to share information on post-op infections or complications with physicians who are competing for the same patients," she says.


For information on accreditation survey experiences, contact:

  • Marcia Knight, RN, BSN, 4000 Mitchellville Road, Suite 302, Bowie, MD 20716. Telephone: (301) 441-3375. E-mail:
  • Gail Lanter, CPC, Administrator, East Cooper Plastic Surgery, 1300 Hospital Drive, Suite 120, Mount Pleasant, SC 29464. Telephone: (843) 849-8418. E-mail: