Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
Issue link: http://outpatientsurgery.uberflip.com/i/1335688
We handled the surprise visit like pros, mostly by being confident in our operations, and we wel- comed suggestions the surveyor gave us. Those sug- gestions, in fact, prepped us for the official survey, which occurred last June. Prepping for a survey and passing it during the pandemic wasn't easy, but here are a few of the valuable lessons we learned along the way. • Everyday excellence. Incorporating accredita- tion standards in your day-to-day work is the best way to ensure your center is ready for a spot inspection or one that's scheduled months in advance. The ultimate solution is to have good prac- tices in place along the way. Continuing education is key to making that hap- pen. Don't put it off because you don't have a sur- vey due for three years. Rather, act as if the survey is coming up soon, so you don't wind up cramming for the inspection. We have an online education platform and staff members have to participate in an annual curriculum. We tweak it slightly each year to keep it fresh, but it includes boilerplate material covering OSHA standards, how to handle biomedical waste, hand hygiene practices and fire safety compliance. Our thought is we don't have to worry about whether staff is up to date on accredi- tation standards if they're educated on the current versions each year. We didn't postpone the survey because of the pandemic, which was an option for us, because we figured if we got through a survey in the middle of a pandemic, we could get through anything. But it also meant we didn't know if the surveyor was going to arrive with increased expectations because of COVID-19. As it turned out, the surveyor didn't come in with a particular emphasis on pandemic-related practices, although he did observe the temperature checks we per- formed on patients and our mask- ing practices. Just to be sure, we kept a COVID-19 book on all the changes we made in response to the recommenda- tions our facility received throughout the pandemic. Maintaining a separate binder is less unwieldly than putting pandemic-related information in our main policy book. We let the accreditation agency's handbook and our previous surveys guide our preparations. We track all notifications of changes to the handbook, then change and track our practices accordingly. Surveyors always ask what we've done to address their notations for areas of improvement during pre- vious surveys, so we presented documentation on the tweaks we made to our credentialing files, physician referrals, peer review processes and pathology reconciliations. An important point to remember is that not every surveyor will be from your state, so they won't always be familiar with the local standards you're following. If you're doing something different than you were doing during the previous survey, be ready to provide the reason why you're doing it — a government document, a study or a link to a web- site — and you'll be in good shape. Don't say, "Well, I remember reading an AORN guideline that said we should start doing this." You need to explain why you made changes, and which organization recom- mended them. 5 2 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • F E B R U A R Y 2 0 2 1 WRITTEN RATIONALE Maintain a list of websites and other documents from organizations that recommend best prac- tices to show surveyors why you've instituted new protocols. Amanda Harris