Surveyors want to see follow up to studies
Surveyors want to see follow up to studies
Med labels, credentialing, staff training important
(Editor's note: This month, we look at tips and suggestions from outpatient surgery programs that have been surveyed by the Accreditation Association for Ambulatory Healthcare. Other tips were in the July 2006 issue of "SDS Accreditation Update," p. 3.)
A focus on the outpatient surgery building, quality improvement, and an emphasis on credentialing processes were priorities for surveyors from the Association for the Accreditation of Ambulatory Health Care who visited two ambulatory surgery centers this year.
"We felt well prepared for our survey because we approach accreditation as an ongoing process and stay abreast of changes as they occur," says Nikki Folger, RN, manager of Aesthetic Surgical Images in Omaha, NE. "I was surprised at the detailed look at our facility," she admits. Not only was the walk through of the facility thorough, with the surveyor looking at all facets of the building, but the surveyor also looked at all maintenance records, she adds.
Inventory records also were examined, but the surveyor did not simply look at the book listing medications and expiration dates. Instead, he also went to the supply room and looked at the medication containers to verify that the labels with expiration dates were in place, says Folger. "In past surveys, the surveyor just looked at our books, so this was different," she explains.
Properly labeled medications in the operating room were a focus of the surveyor who visited the Advanced Family Surgery Center in Oak Ridge, TN. "He looked at the medications on the back table to make sure that all syringes were labeled," says Alana Booth, RN, CASC, administrator of the center.
While in the operating room, the surveyor observed the center's site verification procedure, says Booth. "We follow universal protocol for surgical site identification and write 'yes' on the surgical site, then have the surgeon initial the site to verify it," she explains. "If there are no initials on the site, we do not proceed with the surgery." The surveyor also looked for documentation of timeouts prior to the start of procedures, she adds.
Show changes following PI studies
Performance improvement projects were examined, and surveyors at both facilities focused not just on the fact that studies were undertaken, but also how the information was used to improve the facility.
Kelly Norman, RN, clinical director at the Oak Ridge center, says, "In one of our studies, we evaluated the use of the Neptune Waste Management System [Stryker Instruments, Kalamazoo, MI] compared to the use of multiple canisters to collect surgical waste. We evaluated costs, employee safety, and time involved."
The study showed that switching to the new system not only saved money for the center, but also reduced employee exposure to bloodborne pathogens because employees did not have to handle emptying the canisters after procedures as often, she explains. "We not only saved $9.54 per case, but we were able to increase our operating room turnover time because the new system handles more procedures than the old system," she says.
In addition to performing internal benchmark studies, Folger's surveyor suggested that the center also include some studies that utilize external benchmarking data. "He suggested that we use information in journals or from other facilities to evaluate our performance compared to other surgery centers," she says.
In the surveys of both facilities, surveyors paid close attention to credentialing records. "Even though we are a physician-owned facility, the surveyor recommended that we use the National Practitioner Database for credentialing all of our physicians, including those on our governing board," says Folger.
Booth says, "I was complimented on our system that ties together all of our peer review data with our credentialing records." Her software (AdvantX, Source Medical; Birmingham, AL) enables her to enter all quality or peer review information, then sort by type of occurrence or by physician. "When the surveyor asked to see information on specific physicians, I just entered the physician's name and printed a report," she says. The surveyor liked the easy, efficient access to information, not only for the surveyor's use, but also for management of the facility, Booth adds.
Although her credentialing process was thorough, Booth's surveyor did surprise her with one recommendation. "I have a framed list of the names of our physician owners in the registration area, but he said that I should have a list of all credentialed providers displayed in the lobby or registration area," she says.
AAAHC surveyors also looked closely at employee records. Folger says. "Our surveyor also recommended that we use templates in the back of the accreditation handbook to organize our employee records. Although our records were complete, he suggested that standardizing the order of the records would make them easier to review and evaluate for completeness," she explains. Some programs put a checklist in the front cover of each employee file for managers to be certain all of the information is present and current.
"Above and beyond" were the words used by the surveyor to describe the use of Bispectral Index (BIS) monitors at her facility, says Booth.
"We do an exceptional job in our anesthesia department," she says. Not only has the facility used BIS monitors since the center opened, but the anesthesiologists have developed their own form that describes complications and benefits of anesthesia, but it also serves as an informed consent form for both patient and physician to sign, she says."Employee training and continuing education were important to our surveyor," says Booth. One inservice that Booth's center regularly offers is how to respond to a code when dantrolene is needed. "We have pictures describing how to mix the drug properly, but we give employees a chance to actually mix the drug by using the expired drug vials," she says.
Making sure that her staff members were prepared for the survey meant putting them in the right frame of mind, Booth says. "An accreditation survey is not a punitive thing; it is a chance for us to show off our facility," she says. "I remind everyone that we invited the surveyor, in fact, we paid a fee for the survey, so we want to show how well we care for patients, and we want the surveyor to let us know how we might do better."
Sources/Resource
For more information about Association for Accreditation of Ambulatory Health Care survey experiences, contact:
- Alana Booth, RN, CASC, Administrator, Advanced Family Surgery Center, 944 Oak Ridge Turnpike, Oak Ridge, TN 37830. Telephone: (865) 425-6700. E-mail: [email protected].
- Nikki Folger, RN, Manager, Aesthetic Surgical Images, 8900 W. Dodge Road, Omaha, NE 68114. Telephone: (402) 390-0100. E-mail: [email protected].
For more information about the National Practitioner Database, go to www.npdb-hipdb.hrsa.gov. Query fees start at $4.75 per request.
A focus on the outpatient surgery building, quality improvement, and an emphasis on credentialing processes were priorities for surveyors from the Association for the Accreditation of Ambulatory Health Care who visited two ambulatory surgery centers this year.Subscribe Now for Access
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