By Becky Ziegler-Otis, MHA, CASC, CPHQ, CHC, RHIA
As an Ambulatory Surgery Center professional, you will undoubtedly be faced with preparing for a regulatory survey. This could be in the form of Medicare Certification, Joint Commission Accreditation, or AAAHC Accreditation. Whatever the case may be, your preparation efforts should be continuous or ongoing. Surgery Center Administrators typically wear a number of hats, and it is hard to juggle all that needs to occur on a day by day basis. One starts the day with the best of intentions to focus on preparation, only to find out the center is short staffed, has equipment problems, or has a new staff person being oriented. For this reason alone, it is important to allocate time on a regular basis, such as one or two times a month to this very important function. In addition, setting aside time for this work allows one to continuously prepare and not just think about it three to six months before the expected survey requiring one to feverously assess compliance to the myriad of standards. This can be a daunting task.
Once a set schedule has been established to focus on survey preparation, assure one has a current copy of the standards/regulations or statement of conditions. Regulations and standards change over time, and one needs to assess against the most current version. Validate that there is a process in place to receive regular updates from the certifying/accrediting entity on proposed and implemented changes. This may require signing up for listservs, email updates, reading journals and collaborating with colleagues.
Use the designated time to assess the surgical center against each standard to determine the overall compliance. It could result in needing to locate a specific policy to demonstrate compliance with the standard, which could then lead to talking with staff to determine their awareness of the process depicted in a policy. It could also lead to a process of conducting periodic documentation or observation audits to validate compliance. This is especially important if one has relatively new employees. One may discover the center is not in compliance and due to the complexity of the standard be unsure how to foster compliance, hence the need to reach out to colleagues who can provide various compliance strategies to explore. The value of colleague collaboration is immense.
One may discover areas of concern may need to be assessed on a regular basis, hence the preparations may result in conducting periodic mock surveys, which can serve as another great resource in fostering ongoing compliance.
It is also critical to use the designated time to review any new or changed regulation to implement required modifications in processes or practices to assure the facility remains compliant.
Ongoing survey preparation requires time and commitment. A surgery center administrator will find this is time well spent as the end result will be a continuously prepared facility and one that can demonstrate it continuously provides safe and high quality care.