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Accreditation Dings
Our annual look at the odd and unusual things that surveyors cited surgical facilities for.
Dan O'Connor
Publish Date: August 7, 2013   |  Tags:   Accreditation
accreditation dings WOULD YOU BELIEVE WE GOT DINGED FOR Kim Mills, RN, nurse manager of Western Maryland Health System, stands next to Karen Youngblood, RN, same day surgery charge nurse.

The best accreditation surveyors are helpful, fair and professional. They're thorough but reasonable, and offer constructive comments. The worst are nitpickers who focus on the trivial, whose findings make you roll your eyes, shake your head and shrug your shoulders. Like the surveyor who notes a few strands of hair sticking out of the circulator's hat and cites your facility for a breach in infection control. Like the surveyor who insists that you put an extra illuminated exit light at the end of a hallway that points to the left when there is no other way to go but left. Or like the surveyor who dings you for not labeling the basin of saline on the back table. These are actual dings from actual surveys shared by your actual colleagues. Yes, sometimes it feels as if surveyors have got to write you up for something. Right, Kim Mills, RN?

Roof pollen and protruding pictures
Ms. Mills is the nurse manager of the Western Maryland Health System in Cumberland, Md. Her most recent survey experience was laughably bad. "Pickiest people I've ever seen," she says of the 7 surveyors who camped out at her facility for 5 days in May. "It was awful, the worst we've ever had. We did fine, but it was a horrific experience."

How bad was it? One surveyor noted that there was excessive pollen on the rooftop. "When he said that, I wanted to shove him off the roof," jokes Ms. Mills. "Are you kidding me? We dared him to cite us for that. We told him to come back in December and there'd be no pollen up there." It's become a running joke among the OR staff: "Anybody been up on the rooftop to check the pollen lately?"

Another surveyor complained that artwork adorning the walls in the hallways obstructed patient stretcher flow. "They don't even stick out as far as the guardrails," says Ms. Mills of the canvas-wrapped pieces of art. "The pictures weren't dusty or dirty, and there was no glass. We eventually had that overturned."

Then there was the surveyor who wanted a sign acknowledging the facility's security cameras. Not just 1 sign, but one where every camera was located. "That makes no sense to me," she says.

One ding, however, has caused quite an inconvenience to the surgical services at Western Mary-land. The hospital has been forced to move its bronchoscopies to its intensive care unit. Surveyors correctly pointed out that bronchoscopy suites must be maintained at negative air pressure to eliminate the spread of infectious agents like tuberculosis through the air. Western Mary-land, which Ms. Mills says only performs about 30 bronchoscopies per year, scheduled its procedures as the days' last cases and flipped the room from positive to negative air pressure. No good, said the surveyors.

"We do less than 30 bronchoscopies a year in the OR and they expect you to have 1 room dedicated to this procedure for the whole year," says Ms. Mills. "That is highly impractical and very costly to let an OR be idle for 335 days out of the year."

Rate Your Surveyor

When the surveyor showed up at a brand new ASC "that was still trying to figure out how to be an ASC," the facility had so few paper charts that it didn't bother numbering them. "We were dinged for not using account numbers on the 12 charts the surveyor audited," says the administrator. "An oversight for sure, but the citation was severe for the offense." During your last accreditation survey, was your surveyor too picky? Here are the results from when we asked that question to 123 readers last month:

  • Too picky 26.8%
  • Not picky enough 8.1%
  • Just right 65.0%
rate surveyor

Head-scratching dings
Ms. Mills is hardly the only administrator with an interesting ding story to tell. Casey Mc-Farland, MHA, administrator of the Georgia Endoscopy Center in Atlanta, watched her surveyor break out a stopwatch to time how long it took for CaviWipe surface disinfectant to dry on her bed rails. It dried in less than 2 minutes, so the surveyor told Ms. McFarland her sterilization techs would have to re-wet the rails to allow for adequate contact time.

Speaking of disinfectant wipes, it wasn't enough that the OR staff at one facility knew their wipes' contact times. The surveyor expected them to know how many square feet a disinfectant wipe can cover.

Ruth Maxwell of Kirby Glen Surgery Center in Houston, Texas, still can't believe that a surveyor asked her to prove what the fire rating was for the glass panels within the fire-rated doors.

We heard from a surgery center administrator who was dinged for not having documentation of a correction plan for post-op infections. Turns out there was good reason for that. "We have never had a post-op infection and had documentation of that fact."

Sherry Butts, RN, BSN, the OR supervisor at the Albany (Ga.) Surgery Center, ?blames her surveyor for all the saline and Betadine she's wasting. "He wants us to use smaller bottles of saline and Betadine so we can pour out of them only one time and then throw them away," says Ms. Butts. Trouble is, she can only find Betadine in a 4-oz. bottle. "We are wasting so much money in saline and Betadine because we have to discard it after a single pour."

The surveyor also suggested head-scratching changes to Albany's documentation. Instead of ordering "post-op" X-rays, they now order "discharge" X-rays. Instead of checking patient records daily, the ASC's policy states that they check records "on days of operation" or "Monday to Friday." After all, the surveyor pointed out, the ASC isn't open on weekends.

The surveyor of a 1-OR surgery center took issue with the assignment sheets. "They said we didn't have enough information as to who was working and what their assignments were," says the administrator. Maybe that's because the ASC has the same staff doing the same things every week.

We're not making this stuff up
Like your colleagues, you could get dinged for hanging your lead aprons on pegs instead of hangers. For not checking the temperature of the mini refrigerator that you keep soda in for patients every day (tsk-tsk). For not having combination locks on any doors leading back to patient care areas. For not cleaning your gel pads and labeling your Cidex strips. For not having "topical anesthesia" listed on a surgeon's privileges. For not labeling a syringe during a pain management procedure. For not having signage posted stating you use radiology equipment in the department in case someone is pregnant. "Because we don't do surgery on pregnant patients this seemed to be a bit beyond reasonable," says Audrey Van Veen, RN-C, BSN, MSM, of the MultiCare Health System in Tacoma, Wash.

For using the "wrong" font. "We were using Calibri on both our quality projects and board meeting minutes," says Barbara Marco, RN, BSN, MS, administrator of the Camp Lowell Surgery Center in Tucson, Ariz. "The surveyor suggested Times New Roman or Arial. My nursing director and I came in at 0400 the second survey day to reformat the font on all our documents. I'm not sure he read the content of anything."

For having a thread showing on your OR table pads. For having unsecured emergency medications in a completely locked-down department. Or for having expired medications on your emergency code cart (never mind that you're unable to replace them because they're on back order).

For having a construction exit marked with glow-in-the-dark paper signs that lead through a pathway that was safe, but not intended for patients. For having an unmasked surgeon sticking his head in the OR door to see if the patient was in the room yet.

For letting the circulating RN fill in the immediate post-operative notes that the surgeon signed. For letting CRNA students take verbal orders on pre-written order sheets for the covering physicians, even though the "students" have full RN licenses in the state. "They were not writing new orders, only signing pre-printed order sheets as verbal orders from the physician," says anesthesiologist Joe Travis, MD, of Glenwood Regional Medical Center in West Monroe, La. "The orders were for routine CBC and IV starting on OB patients."

For not having an anesthesiologist or a pharmacist present when medicating patients post-operatively ... with a Percocet. For not having enough emergency battery-powered lights should you lose generator power.

Yes, some good advice
Not all dings are nuisances. Some are downright helpful. One facility manager was puzzled when her surveyor dinged her for not having dantrolene on site to treat malignant hyperthemeria. "All of our cases are either MAC or local anesthesia," she said in protest. All facilities that administer MH-triggering agents, specifically the volatile anesthetic agents and the neuromuscular blocking agent succinylcholine, should stock a minimum of 36 vials of dantrolene sodium for injection. If triggering agents aren't used, then dantrolene need not be present. Still, there have been reports of MH episodes occurring even with the use of "safe" agents.

Andrea Fann, administrator of the Orthopaedic South Surgical Center in Morrow, Ga., says her surveyor suggested an additional battery backup light in each area where they administer anesthesia blocks. "We ended up adding an emergency ballast to all 12 of our bays, as well as our ORs and treatment room," she says.

The surveyor at Sutter Tracy (Calif.) Community Hospital helped the facility revise its laryngoscope blade policy to make it more complete. "We implemented it immediately," says Cheryl Steensma RN, BSN, Sutter Tracy's policy and procedure coordinator. "Our surveyor really wanted to work with us as far as evidence-based practices and patient safety goes, so overall it was a good outcome."