A missing expiration date. On a bottle of glass cleaner. That's it. That's the only thing that the accreditation surveyor dinged The Surgery Center in Middleburg Heights, Ohio, for.

"If that's the worst thing she found out, cool," says Administrator Barb Draves, LPN, CASC, who, at her surveyor's behest, called the glass cleaner manufacturer to get a recommended expiration date. "You figure that you have to get dinged on something. I can deal with that."

Speaking of expiration dates, a surveyor gave Nancy Burden, RN, MS, CPAN, CAPA, an RFI (requirement for improvement) because he found 1 tube of glucose test strips that didn't have an expiration date. "We always use the strips long before they become outdated, but we do understand that we missed the requirement," says Ms. Burden, the director of ambulatory surgery for the BayCare Health System in Tampa Bay, Fla.

Give much thought to where the trash can in your restroom is? "One surveyor dinged us because our trash can wasn't next to the bathroom exit, but was closer to the sink," says Sharon D. Bowen, CASC, a vice president of operations with the corporate partner ASCOA. "According to him, this was an infection control issue. We moved it 2 feet and it was OK."

Petty? Picky? Perhaps. "Some surveyors think that if they don't find something wrong, they're not doing their jobs," says a surgery center administrator who asked to remain anonymous. "I said to ours at one point, ???I thought these surveys were to be educational and fun.' He just looked at me and didn't say anything. It was neither. He was out to get us."

As the following dings show, you can commit your accreditation handbook to memory and run 12 mock surveys, and chances are you won't escape your survey unscathed.

How wide is that sliding glass door?
A quarter of an inch. On a sliding glass door that leads to the restricted area where both ORs are. "The surveyor took out a tape measure," says the director of surgical services at a New Hampshire hospital who asked to remain anonymous. "The door opening was a quarter-inch too narrow."

Never mind that Medicare had reviewed and approved plans for the 2 ORs. The surveyor insisted on a wider door. The cost to replace it: about $25,000. The door was about $8,000; the rest of the cost went to breaking through cement, flooring and sheetrock to create a doorway that's 18 inches wider.

"So we didn't interrupt surgery, we started Friday evening and worked through until early Sunday morning," she says. "That meant paying demolition crew and construction people a weekend/night rate."

Battery-powered emergency lights in OR
Did you know that every month you must check the battery-powered emergency lights that are required in the OR or any other area where patients are anesthetized? Neither did Sandy Berreth, RN, MS, CASC, the administrator of the Brainerd Lakes Surgery Center in Baxter, Minn.

"I just finished my survey and I truly didn't know that the battery lights in the OR must be checked every month," she says. "Yikes, he got me on that!"

The monthly test requires you to cut all power in your facility for a total of 30 seconds and run your backup lights. And once a year, you must test the backup lights during a 90-minute power outage. It's a requirement of the National Fire Protection Association 70, National Electrical Code. The reasoning: In case of a power outage, you have to be able to see in the ORs.

In addition to including monthly power outage tests in her plan of action, Ms. Berreth keeps flashlights in each of her 3 ORs and 1 procedure room — "a backup for the backup " that she also tests monthly.

Acute pain and pregnancy in ophthalmology centers?
The typical cataract patient is in no danger of experiencing acute pain or being pregnant. That didn't stop surveyors from dinging ophthalmology centers for not having policies in place to deal with these occurrences.

As an ophthalmic surgery center doing primarily cataract surgery, "we don't deal with acute pain at all. But we got dinged for not having a policy detailing how we handle patients in acute pain," says Jackie Dayton, RN, nursing supervisor at Surgery Center of Ophthalmology Consultants in Fort Wayne, Ind. "So I spent an hour writing a policy for something that will never occur in our facility. Seems like a waste of time."

Samantha Cooper, RN, nursing director at the DuPage Eye Surgery Center in Wheaton, Ill., says her surveyor lectured her for about 2 hours on clia-waived pregnancy tests. "I would say at least 98% of our patients are well beyond childbearing age," says Ms. Cooper. "After I stated we would purchase the correct pregnancy test and had my purchasing person write it up, [our surveyor] continued to discuss the situation into the next day. I just thought there were more important things to worry about."

What time is it?
The surveyor at a rural ASC wondered why a cataract patient's record indicated that the PACU arrival times were a minute apart. The patient arrived in PACU at 1:58 p.m., according to the anesthesia record, and 1:59 p.m., according to the recovery room nurse. It turns out that the anesthesiologist used the watch on his wrist while the nurse used the atomic clock on the wall.

The administrator, who asked to remain anonymous, bought 9 atomic clocks ($20 apiece) for her 1-OR, 1-procedure room center and hung them up everywhere — "We have them on different sides of the room so no one's view is blocked" — and made a policy that all staff go by atomic time and not by personal watch time. "This was one of my easier plans of correction," she says.

Service dogs and color blindness
What's your policy on seeing-eye dogs? "In a previous facility, a surveyor asked if we allow them in the OR," says Bonnie Brady, RN, the administrator of the Specialty Surgical Center in Sparta, N.J. Ms. Brady first thought that an anesthetized patient wouldn't need a seeing-eye dog in the OR, but later added a policy allowing service dogs in the main admitted area. That same surveyor also asked if she screened her staff for color blindness.

The art of interpreting standards
The secret to a successful accreditation survey? "Know your standards inside and out — and understand how they're interpreted in practice," says longtime surveyor Barbara Ann Harmer, RN, BSN, MHA, a senior consultant with Healthcare Consultants International in Vero Beach, Fla. She demonstrates her point by way of an example: An accrediting body may stipulate that you must document patient allergies and sensitivities in a prominent and consistent location in the medical record. Your surveyor may interpret "prominent and consistent" to mean the front cover of the patient's chart. "But look closely at the standard: That's not what it says," says Ms. Harmer. "If you list allergies and sensitivities prominently and consistently on the second page of your medical records in each and every case, you're still in compliance with the standard."

Knowledge truly is power during a survey. When you understand not only what the standards say, but also what they mean, "you can tell the difference between an objective interpretation of them and a subjective interpretation made by your particular surveyor," says Ms. Harmer.

Robert P. Hillstrom, MD, president of Hillstrom Facial Plastic Surgery in Sarasota, Fla., has been dinged by past surveyors for "things that we thought were quite trivial." At his most recent survey, his inspector found a single deficiency: the lack of documentation of ASA status on the pre-operative checklist. "It was, of course, documented on the anesthesia assessment sheet," he says. "Aside from this comment, we passed with flying colors."