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Will you be caught off guard at your survey? Focus on infection control, patient safety
Outpatient surgery managers going through accreditation by The Joint Commission and Accreditation Association for Ambulatory Health Care (AAAHC) say the surveyors are targeting two primary areas.
Kate Moses, RN, CNOR, CPHQ, quality management coordinator at Medical Arts Surgery Centers (MASC) in Miami, went through extensive three-day Joint Commission surveys at both of her centers. "Certainly their main focus was patient safety and infection control issues," Moses says. Also, because they were deemed status surveys, the Medicare standards played a significant role, says Moses, who also is chair of the Ambulatory Surgery Specialty Assembly, Association of periOperative Registered Nurses, Denver.
The Conditions for Coverage for ambulatory surgery centers that took effect in May 2009 have been the focus of recent Joint Commission surveys at two Titan Health Corp. facilities, says Roseanne M. Ottaggio, MSN, RN, CDE, CASC, regional vice president, based in New Jersey, for Titan. Titan is a national surgery center developer and operator based out of Sacramento, CA. Surveyors asked questions based on Medicare's Infection Control Surveyor Worksheet. "The facilities completed the survey prior to the JC survey to help prepare for the site visit," Ottaggio says. [The worksheet was included in the online June 2010 issue of Same-Day Surgery. For assistance, contact customer service at (800) 688-2421 or firstname.lastname@example.org.] Two of the most challenging standards were identification of risk for infection and reducing those risks, Ottaggio says.
Surveyors wanted to see their procedures for handwashing, she says. They looked at how the facilities were cleaning the ORs and induction bays. Also, as part of the patient tracer, surveyors watched handwashing and glove use.
"When he was in the preop holding area, and the patient was getting moved out, he asked, 'What happens here in the room now that the patient's gone?' He wanted to hear we were wiping everything down before the next patient was brought into that bay," Ottaggio says.
In the OR, surveyors were watching for sterile technique. "They wanted to see that people had gloves on if they were touching the patient or coming into contact with anything," she says. "When removing gloves, they wanted to know, were they washing their hands."
Surveyors also wanted to see the sterile processing area. "They watched them clean the instruments after a case and get reprocessed," Ottaggio says. "They wanted to see what we were doing in terms of documentation. They wanted to know if a tray didn't pass sterilization, what would happen."
At OA Centers for Orthopaedics in Portland, ME, which recently went through AAAHC accreditation, surveyors verified that the centers had good staff training so staff understood the policies and procedures in infection control, says Lynn Shorty, BSN, RN, director of patient services.
At Tucson (AZ) Orthopaedic Surgery Center, which recently went through a AAAHC survey, handwashing was "a real point of emphasis" for surveyors, says Stuart Katz, FACHE, CASC, executive director. "It was one of those things that both AAAHC and folks from the state licensing department looked at every time they saw someone with a patient," Katz says. They wanted to know whether staff washed their hands before they saw a patient and when they were done, "every time they took off gloves," he says.
Katz said the managers had talked with staff "ad nauseam" about it. "It seems to have sunk in," he says.
Staff should expect to be asked about the policy on handwashing. "It's a case of they need to be articulate on the policy," he says. They also need to know the policy is being followed and where to find the policy if someone wants to see it, Katz says. "That's how they check to see how information is disseminated from the top to the bottom, or the bottom to the top," he says. The emphasis on vertical communication was echoed by other sources interviewed by Same-Day Surgery.
Surveyors ask about patient safety
At MASC, surveyors asked a large number of questions about medication management and safety, including single-dose vials, labeling, and administration of medications, Moses says.
In Tucson, the surveyor was focused on the life safety code. "He was checking for fire penetrations, proper signage, generator testing," Katz says.
Two staff members at his center perform a monthly safety check with a checklist that examines items such as the fire sprinkler system, ceiling penetration, lighted exit signs, and fire extinguishers. [That checklist is included.]
Surveyors are looking beyond the surface, Moses advises. "Surveillance and monitoring of safety and compliance are important, but they are very tuned into what you do with that data and how you improve or maintain compliance," she says. "Frontline staff need to be able to speak to their roles and to address patient safety." Use reinforcement and repetition to help them reach the place where they are comfortable discussing those issues, Moses advises.
Warnings: Surveyors look at previous surveys
If you had a previous accreditation, know that your surveyors will be looking at them before they visit your facility again.
"If you don't incorporate some of their suggestions, you have to be prepared to explain why," says Lynn Shorty, BSN, RN, director of patient services at OA Centers for Orthopaedics in Portland, ME.
For example, Shorty is expecting to be challenged at her next survey because surveyors want her to increase chart review in terms of frequency and number. "It would be an administrative nightmare at the level they are requesting," she says. "We are meeting the requirement, but they would like us to bump it up a notch."
Shorty says she might have to say she can't do it at the volume they're recommending. "I will convince them why our process is just as effective," she says.
You can challenge a surveyor, says Kate Moses, RN, CNOR, CPHQ, quality management coordinator at Medical Arts Surgery Centers (MASC) in Miami. "At one center the surveyor called into question the use of fanny packs for anesthesia's controlled drug supplies," Moses says. Her center performed a quick failure mode exercise that proved keeping the medications in a fanny pack worn by the anesthesia professional didn't alter the drugs' stability or efficacy. "This won praise from the surveyor," Moses says.
Consider these other suggestions:
Read the standards.
Read the manual thoroughly and contact the accreditation group if you have questions about interpretation and specific requirements , says Debra Stinchcomb, RN, BSN, CASC, consultant with Progressive Surgical Solutions in San Diego, which provides consulting services to ambulatory surgery centers. Stinchcomb also is vice chair on the Ambulatory Professional Technical Advisory Committee (PTAC) for The Joint Commission.
The accrediting groups "are very receptive and will spend as much time as needed with clients," Stinchcomb says.
Know that there are symbols in the manuals to assist with compliance, she says. For example, in The Joint Commission's ambulatory manual, a D with a circle around it indicates that something must be in writing. "There is also a list of items that must be documented, Stinchcomb says.
Perform a walkthrough or a mock survey.
Laurie A. Dorr, RN, CNOR, RNFA, compliance specialist/clinical educator/infection control officer at OA Centers for Orthopaedics, says, "I would say getting ready for survey, it's helpful if you do a walkthrough of facility before from a surveyor's side." For example, are hallways cluttered? Are items in open closets neat and tidy? "There are things you walk by every day that you don't necessarily open and look at," Dorr says.
Surveyors will pull out hydrogen peroxide in a closet and look at the expiration date, Shorty warns. "You have to go through with almost a microscope to make sure and go through your workspace with a keener eye than a surveyor would," she says.
Mock surveys can be performed by the facility, a consultant, or the accreditation group. Stinchcomb says, "This is the best way to determine areas that need improvement as well as to ensure them of survey readiness."
Receive and share ideas with your surveyors.
Surveys can be a give-and-take process in terms of idea sharing, says Stuart Katz, FACHE, CASC, executive director. Tucson (AZ) Orthopaedic Surgery Center.
For example, his surveyor liked the way his staff conduct drills and document them, Katz says. The director of nursing and Katz assign staff responsibility for the drills. "The staff figures out the scenario, runs the drill, runs the critique, and writes it up," he says. The advantage? "You get buy-in from the staff," Katz says.
Another area that made an impression on his surveyor was that checklists are placed in applicable work areas. For example, the checklist for spore testing of sterilizers is kept in the sterilization area. The checklist is completed in the work area, then added to the record books in a central location. "The thinking is that is should all be centralized," which can be a problem, Katz says. While the checklists need to be in a central location when they're completed, staff doesn't always remember to go get the sheet when it needs to be completed. Having the checklist in the area addresses that problem.
His surveyor shared her interesting tickler system. Her system is taken from the area of the manual for the Accreditation Association for Ambulatory Health Care (AAHC) where it explains requirements for the board. She puts those items on a page that is never published. When compiling the agenda for her next quarterly board meeting, she puts 25% of those items on the agenda. The same items are discussed at the same quarterly meeting every year. This system allows her to continuously check off items and ensure they are completed. "We've never seen it done that way, Katz says.
Ask your surveyors questions, says Roseanne M. Ottaggio, MSN, RN, CDE, CASC, regional vice president, based in New Jersey, for Titan Health Corp. "You requested and are paying them to be there, and it should be a learning and collaborative effort," Ottaggio says. "I found the surveyors are very knowledgeable and willing to share how to improve different areas."
Lastly, continuously prepare, sources advise.
"We tend to be always working toward Joint Commission and [Medicare] compliance," Moses says. "We have ongoing initiatives with staff and physicians to keep us in the ever-ready mode." (See a survey "don't," below.)
Don't overwhelm with documentation
OA Centers for Orthopaedics in Portland, ME, learned the hard way that trying to be helpful to surveyors can backfire.
"I remember the first time years ago, we thought we would be one step ahead by bringing all documentation into one room, so they wouldn't have to ask for anything," says Lynn Shorty, BSN, RN, director of patient services. "They were overwhelmed by the volume of materials we had for them to review."
Now the staff wait until surveyors ask for information, and then they provide it to them. Also, organizing the information, such as personnel folders, can help surveyors, Shorty says. Because her centers have many employees with longevity, those folders are fairly thick, she says. "It can be helpful to have a table of contents for each personnel file so that each file is organized in the same way," Shorty says. "Instead of going through the contents, they could look at the summary sheet."