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Freestanding surgery center goes from zero to being fully accredited in just 90 days
Do you need to gear up for an accreditation survey in a short amount of time? One surgery center went from being a new center with policies and procedures that were inadequate to achieve accreditation to being fully compliant with accreditation standards in 90 says, and they probably could have been ready in 60 days, according to the consultant who assisted Spring Surgery Center in The Woodlands, TX, with the process.
Richard Bays, RN, MBA, CPHQ, CLNC, of R Bays Consulting in Houston, TX, says the first step was to identify their resources in terms of staff and their expertise, and the second step was to assign oversight of appropriate chapters of The Joint Commission standards manual.
All of the RNs, plus the materials management staff person, were assigned 2-3 chapters each. "We assigned different chapters to the people most likely to be leaders of those areas," Bays says. For example, the materials management staff person handled compliance with biomedical issues and the Occupational Safety & Health Administration (OSHA).
The staff looked at their policy manual to determine how to make their policies compliant with all of the accreditation criteria. "There were a lot of things we didn't have in there," says Leslie Jernigan, RN, BSN, clinical nursing manager.
Bays provided basic templates, based on the center's specialties and operational guidelines. "Everyone does things differently," he says. The center can tweak areas, such as how they handle their sterilizer.
One area the staff re-examined was a section on emergency management. "We're ambulatory, so our `what to do in an emergency' was save a life and get them out of there," Jernigan says.
The staff had to specify who they would contact and how they would get patients to a hospital. The staff also had to spell out their contingency plans for disasters such as tornados, hurricanes, and chemical disasters. The policy explained: "Would we take patients? No; we would not take patients in case of an emergency. We don't have an ER; we don't admit patients," Jernigan says.
Revising the policies was a lot of work, she says. "To give us some incentive, the owners gave us monetary compensation for the extra work," Jernigan says. Staff did the survey preparation in their spare time. "When we had a couple of days when we weren't busy, we would work on it for five or six hours," Jernigan says. While the monetary compensation helped as an incentive, the staff knew they had to pass accreditation, she says. "We certainly would have had very decreased patient volume" otherwise, Jernigan says.
Once the policies were revised, Bays would review them and revised the wording as needed. During the survey, the surveyor spent an entire day going through the policies manual, Jernigan says.
Educate, educate, educate
Bays also provided focused education for leaders of areas that he knew would be a focus for The Joint Commission.
"Infection control is an extremely popular now, for state or federal surveys," he says. "We identified who would be spearheading that area, and we made sure the specific EPs [elements of performance] were in place."
Life safety code is another important area, Bays says. "Firewall penetration is a focus review," he says.
A third area is medication management, which includes safely administering medications. Also, surveyors have been looking closely at employment records and physician credentialing. "They are making sure we have proper licensing and credentialing for the physicians, and also records for the employees," Bays says. For this reason, one area of focus is the human resources standards, he says.
Another strong focus is communication, Bays says. "They want to see you can demonstrate communication up and down the chain of command," he says. "They want you to have processes in place so that information can flow in both directions as changes are identified."
The education included mock surveys, a Q&A session, and a general educational session with booklets of what staff could expect in different clinical areas, such as the surgical suite. For each area, Bays told staff what questions they were most likely to be asked and what standards the surveyors would want to see demonstrated. "No one was surprised" at the survey, he says. [see example of department-specific questions to prepare for a survey.]
When facilities run into major problems during their survey, it's usually because there's been a breakdown between what is required in the accreditation manual and how the standards are implemented, Bays says. It's not that staff members are unwilling, he says. They simply don't know how to put practices into place that will appease the standards, Bays says. "You need someone knowledgeable to communicate in a teaching session, not "here's a quick answer sheet for a test," he says.
The key to getting ready for a survey in a hurry? "I think that with proper leadership and guidance, it does put you ahead of the game, but you need the raw talent of your employees and systems in place," says Bays. "That's a necessity."
The staff were pleased with the outcome of their survey. Jernigan says, "We passed with flying colors. I think they were quite impressed with everything that was documented." (For information on how staff at a surgical hospital prepared for its first survey in 30 days, see story, below.)
Getting ready in a hurry? Learn from this facility
Humble (TX) Surgical Hospital originally was an ambulatory surgery center (ASC) owned by one physician, but it evolved into a surgical hospital owned by several. The ASC had never been accredited, so when it was preparing for its first accreditation survey, "we literally started from scratch," says Carla Turner, RN, director of quality and performance improvement.
The staff moved into the new facility in August and had three months to write their policies and put them in place, Turner says. "A great group of people jumped in," she says. "We didn't know where we were going or what was expected of us."
Turner started by attending a summit conducted by her accrediting organization, The Joint Commission, which she highly recommends for those preparing for their first survey. "I received a wealth of knowledge during those days," she says. The presenters went through the standards page by page, Turner says. They explained details, such as the fact that a triangle with a "3" in it means it has direct impact on the survey. "If you miss one of those, you have an increased chance of being cited," Turner says. "We knew where to focus."
The presenters also explained how accredited facilities have access to The Joint Commission extranet, which has a significant number of resources, she says.
Starting with the standards
Turner used the standards as an outline for her policies and procedures. "It was a work in progress," she says. "We had a lot to do in a short period of time."
The standards were a greater help than trying to rewrite someone else's standards or trying to write policies based on the extensive Life Safety Code, she says. While there are plenty of policy templates available for purchase on the Internet and from consultants, your policies need to comply with your state's regulations, Turner points out.
"We kept in close ties with the Life Safety Code handbook and the Texas Administrative Code," she says. "I think in all honesty, if we hadn't had The Joint Commission standards to build upon, we would have been running in circles," Turner says.
By following the standards, "we could not only get accredited in a short time, but we had everything they require and more."
Along with her administrator, Julie McKay-Smart, Turner assigned pieces of the standards to the facility's other eight directors who each oversaw a specific department, such as preop or PACU."All I can say, honestly, is that a single person can't do this," Turner says. Those directors put together policies and procedures on those standards and brought them to Turner to type in. That core group met weekly to discuss their progress. Policies and procedure changes and new forms must be reviewed and approved by the governing body, and that approval must be documented.
All of this work happened when the surgical hospital was open for business. "It was very challenging," Turner says. "There were a lot of 12- and 15-hour days."
One critical piece of the survey preparation was having a mock survey.
"When the mock surveyors came in, they were tougher on us than the Joint Commission," Turner says. "They really helped us. We were 80% finished, but they were able to pull in and show areas we needed help in."
For example, the staff thought they had a good system for medication management, but there were areas of the documentation that weren't 100% clear, she says. "They identified those issues," Turner says. "We went back to the standard, and we wrote our documentation to better reflect the standards. So we were right on when the true survey happened."
Using an outside consultant for the process was a huge help, she says.
The consultant, Richard Bays, RN, MBA, CPHQ, CLNC, with R Bays Consulting in Houston, TX, spent 30 days with an "intense plan" that focused on the major accreditation issues for the facility. "I'm not saying there is anything you shouldn't be in compliance with, but the major areas you know they will look, you should focus on that," Bays says.
For example, in the OR, the surveyors will want to see that the time out is performed properly and that there are proper infection control practices, including proper sterilization of equipment, he says.
"There may be some small detail missing about documentation of something that's not common you might fall short on something like that but if you're delivering safe patient care and adhering to standards of practice, you'll have a much easier time to ramp up for surveys," Bays says.
One of the most important areas of preparation is telling members of the staff what the survey will be like, he says. "A lot of it is being nice to surveyors," he says. "They're working hard to evaluate massive amount of information in a few short days. Whatever you can do to make it easier to surveyors, by finding information, being more open in your communication with the surveyor, that will facilitate that survey to go smoother."
To others who have a short time to gear up for their first survey, Turner offers these encouraging words: "It's not impossible," she says. "It can be done."