SDS Accreditation Update

Surveyors interact more with staff and patients

Organizations put less reliance on paper reviews

Although the approach differs from surveyor to surveyor, same-day surgery programs that recently have undergone accreditation surveys notice that surveyors are more interactive with staff and less reliant on policies.

The staff at Northeast Missouri Ambulatory Surgery Center in Hannibal experienced their
first accreditation survey by the Accreditation Association of Ambulatory Health Care (AAAHC) in Wilmette, IL, in December 2002.

"Because it was our first survey, the surveyor spent the first day meeting with the administrator and managers, as well as specific staff members with whom he had set appointments," says Brian Shelton, MBA, administrator of the surgery center.

"During the tour of the facility, however, the surveyor asked questions of staff members he encountered," he says. The questions ranged from what to do in case of a fire to how medications are handled, he adds.

His staff had no problems handling the questions because in addition to reinforcing key policies such as helping patients with language difficulties, responding to code 1, and procedures to follow in case of a fire, his staff of 20 completed the application for accreditation as a group, says Shelton.

"Everyone was familiar with the information that AAAHC wanted, and everyone had provided input into the final application," he says. This involvement, along with a mock survey conducted five months prior to the survey, meant that there was no anxiety on the staff’s part, he adds.

The Joint Commission on the Accreditation of Healthcare Organizations’ surveyor for Greenville (SC) Hospital System’s surgical services area also was very interactive with staff members, says Colleen J. Trask, RN, CNOR, director of perioperative services.

"He did not ask to see the written policies but asked staff members about a number of things as he walked through the department," she says.

Specifically, he talked with the certified registered nurse anesthetist (CRNA) about the control of narcotics, says Trask. "He wanted to know exactly how we secured narcotics, document the administration of narcotics, and return the narcotics to the pharmacy," she says. "He complimented us on our random checks of narcotics to make sure that the vials contain the proper dose when returned to storage."

One suggestion that Trask offers is that same-day surgery programs pay attention to empty bottles as well.

"We are now expected to track empty vials of inhaled anesthetics and return the empty vials to the pharmacy for disposal because there have been reports of deaths after people have inhaled fumes from empty vials," she says.


For more information about survey experiences, contact:

  • Brian Shelton, Administrator, Northeast Missouri Ambulatory Surgery Center, P.O. Box 511, Hannibal, MO 663401. Telephone: (573) 221-1931.
  • Colleen J. Trask, RN, BS, CNOR, Director of Perioperative Services, Greenville Hospital System, 701 Grove Road, Greenville, SC 29605. Telephone: (864) 455-3224. E-mail: