Here’s what everyone about to be surveyed has in common: Fear.
“Because of that fear factor, staff and administrators fear the process instead of looking forward to the process,” says Sandy Berreth, RN, MS, CASC, administrator of Foothills Surgery Center at Sansum Clinic in Santa Barbara, CA. Berreth speaks about regulatory and accreditation issues at national conferences and has served as a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC).
“I tell people that if you know what you are doing, you don’t have to fear any surveyor,” she says. “Whether it’s a federal surveyor, state surveyor, or organizational surveyor like The Joint Commission, we’re there to follow the rulebook.”
Surveyors follow specific guidelines in Appendix L of the Medicare Conditions for Coverage for ASCs as found in 42 CFR 416. To fly through the survey, all an ASC needs to do is read, understand, and adhere to the guidelines, Berreth says.
“The key is to not try to cram it in a month before your application is due at your accrediting body,” she says. “If you do that, you’ll find yourself hyperventilating and having palpitations, and that’s not good for anybody — not good for you, and especially not good for your staff.”
Berreth offers the following suggestions for how to prepare for a survey:
- Create a survey readiness team. A survey readiness team can make sure certain processes and documentation are compliant. They can be on constant lookout for issues, and can conduct a walk-through to make sure documentation and processes have met the standards, Berreth says.
“You don’t have to do the walk-through monthly; quarterly is fine, or every six months” she says. “But if you do it annually, you miss a lot, so I recommend bi-annual at least.”
The walk-through should note whether staff and physicians are following the guidelines. It might reveal another strategy to emphasize to everyone who walks through the surgery center that the ASC makes accreditation and standards a high priority, she adds. It also helps to rely on the team approach as surveyors usually ask direct staff, not just administrators, why they follow certain practices.
- Pay attention to organizational details. Surgery centers struggle with organizational practices, Berreth notes. This includes administrative functions such as holding board and committee meetings that, on a regular basis, address required standards such as a comprehensive review of the infection control program.
“What happens is organizations are not prepared and try to prepare in a small amount of time, and they do that badly,” she explains. “The staff is not prepared for questions surveyors ask.”
The way to prevent that deer-in-headlights look when asked a question during a survey is to know the standards and to keep them current, Berreth says.
Standards are the rules organizations follow. If the standards are not current, then it’s like playing a game without a rule book.
- Learn the right way to handle credentials. Organizations sometimes over-credential, or they think it’s much harder than it needs to be, Berreth says.
“Credentialing is one of the hot topics organizations are trying to get better and better at,” she adds.
ASCs sometimes handle credentialing incorrectly, leaving room to improve their process through consistency. For example, one best practice in handling credentialing is to create a schedule that puts everyone on the same cycle, she suggests. Also, ASCs must show they understand the difference between credentialing (verifying and assessing qualifications, such as training) of a provider and privileging (periodic peer review of clinical performance and adherence to standards of care).
- Evaluate the delineation of privileges (DOPs). “Delineation of privileges needs to be extremely well evaluated, especially at reappointment time,” Berreth says.
“You need an active list of what surgeons are doing,” she adds. “One of the things I have found that works is to not be specific, to always be general.”
For example, if a surgery center has Medicare procedures and CMS accreditation, then the center’s scope of practice should include every Medicare CPT code, and physicians reserve the right to perform any of the coded applicable procedures. The DOP will say what a specific doctor can do, listing the CPT codes. The physician must review the list and verify that he or she can carry out each of these items.
“Then the list goes to the medical advisory/executive committee, and their peers can agree he can do these,” Berreth explains. “Then those privileges are granted.”
Organizations must understand that they have to request the DOP, then proceed through the process and document that the physician can perform each listed procedure.
“Organizations have DOPs, but they don’t have them marked as to what procedures the physician is actually requesting to be done,” Berreth says.
Also, to add new surgeries to the DOP, surgeons must work with administrators, who write a letter or email to the center’s board, stating that the physician would like to conduct a new procedure and has completed the required training to do so, she explains.
“Then, the peer board members can say, ‘Yes, that’s fine,’ and they’ll grant those privileges based on the information,” Berreth says. “Then the administrator can print out the emails, put those with the surgeon’s delineation of privileges, adding this one procedure.”
The process has to be followed, and while it’s not difficult, it does have to happen, she adds.
- Complete infection control worksheet. “This is not a big thing to surgery centers, but it is to surveyors — the infection control worksheet that CMS has out,” Berreth says.
“Every surveyor looks at that document a little differently,” she says. “We as surveyors are going to walk into an organization, and we’ll base our infection control survey on interpretation of CMS worksheet guidelines.”
If a surgery center only bases its infection control on federal rules, there is a risk of being out of compliance with a particular state regulation, or with an association’s guidelines, or the healthcare organization’s own rules.
One example involves rules about nail polish and gels. The conservative approach by the Association of periOperative Registered Nurses (AORN), and also recommended by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA), allows only nail polish. Nail extensions, gels, and artificial nails should not be worn in the operating room because of infection risks, Berreth says.
“On the Centers for Disease Control infection control worksheet, it says that artificial nails or gels are not worn by anyone providing direct patient care,” she says. “A gel is a new type of nail polish that is thicker and UV cured.”
It’s a hot topic for nurses, who are constantly washing their hands and using alcohol rubs. Nurses often think of nail polish as a way to protect their nails, she adds.
Another infection control issue involves wearing masks in the operating room.
Doctors and nurses sometimes take down their masks and leave them hanging around their necks as they walk into other areas. This is something that a surveyor would note, Berreth says.
“When you are breathing into the mask, the mask is filtering bacteria,” she explains.
But when a nurse or doctor pulls off the mask and walks up to someone, there is the potential of spreading bacteria, so the healthcare provider should always dispose of the used mask and re-mask, she adds.
“It’s the same thing with slinging a stethoscope around the neck,” Berreth says. “It drives surveyors crazy when they see that three of your nurses have stethoscopes around their necks.”
Remember to institute disinfection policies for these kinds of items, she advises.
Reusing syringes that are attached to IVs also is a habit that would land an organization in trouble with a surveyor, Berreth says. Infectious disease experts now know that there is a problem with back-up fluid that makes this reuse unacceptable.