Learn to Love Your Accreditation Surveyor


Embrace those dings as opportunities for improvement.

Yes, accreditation surveys are all but guaranteed to cause you some degree of stress. But a sense of overwhelming dread shouldn't accompany a surveyor's visit to your facility. In fact, accreditors are working hard to ensure facilities see the survey process as collaborative rather than combative. Still got doubts about surveyors' motives? We talked to 4 of your fellow facility leaders who said the accreditation process provided key insights that led directly to changes they were more than happy to make.

1. DEA controlled substances audit

When you keep meticulous real-time records of all the medications you dispense, certain things may seem redundant. That's what William Greene, Jr., MD, the medical director of Lakeshore Surgical Center in Gainesville, Ga., thought when a surveyor suggested that his ASC conduct a biannual audit of all the controlled substances on hand that day.

"We have complicated records where we note every single medication that was given — who gave it, how much was given, the patient's name," says Dr. Greene. "With all of the info we regularly collected, I didn't think we needed the [biannual] audit."

But sure enough, when he read the law the surveyor cited from the DEA's Diversion Control Division (osmag.net/ eSrTQ5), there was mention of the need for a biannual inventory of controlled substances. The surveyor didn't suggest the audit to meet his accreditation agency's standards, but to keep Dr. Greene's facility safe in the event it ever had an unexpected visit from the DEA.

"We do the bi-annual narcotics audits on a specific date every 2 years," says Dr. Greene. "We simply write down the drugs, amounts, strengths, number of tablets and number of vials."

On top of giving your facility an extra layer of documentation to prove what it did or had in the event there was a narcotics theft or a diverter made off with some controlled substances, it also ensures you don't get hit with a significant federal fine.

"If the DEA shows up and you have the narcotics inventory info, you're in good shape. If not, you wind up $14,000 lighter," says Dr. Greene.

2. Pending board approval

While surveyors often cite deficiencies you need to correct, sometimes they'll also point out things that, while not technically ding-worthy, you could do better. That's what Joyce Mackler, RN, MSN, CASC, the manager at Seaford (Del.) Endoscopy Center, learned during a recent survey.

"Yes, the entire survey process was time-consuming, but however annoying it was at the time, it really did improve the safety of our patients."
Mary McIntyre, RN, BSN, CRCST

While reviewing the minutes of Seaford's board meetings, a surveyor noticed that some meetings were held just to approve new or revised policies and procedures. This led to having more board meetings than necessary and also led to important policy change delays — sometimes for months at a time. The surveyor pointed out that the governing board can designate the medical director or president of the medical staff to approve certain changes — things like granting temporary privileges, overriding limits on purchases of essential items and adding or removing items from the formulary list — pending final board approval. At a governing board meeting, Ms. Mackler asked the board to grant the medical director the authority to approve or deny any policy, procedural and operational changes pending final approval at the upcoming board meeting. The board granted the designation.

"This was an eye-opener for us. It was such a small change, but it made a really big difference," says Ms. Mackler. Now, even though the board eventually OKs small-but-important policy and procedure changes, the center doesn't have to wait for the annual meeting for those changes to take effect.

"Be sure to update the designated person's formal job description to account for the new responsibilities," says Ms. Mackler.

3. Antibiotic timing errors

The staff at Ashton Center for Day Surgery in Hoffman Estates, Ill., is glad its surveyor noticed their occasional IV antibiotic timing errors. As you know, you need to administer most prophylactic IV antibiotics within 60 minutes of the start of surgery. When the surgery starts outside that window, Medicare requires that you report it. Yet for many facilities, this time frame is challenging due to long-running cases, or prepping or positioning delays.

"Our director of nursing started tossing around ideas with the surveyor about how we might fix the timing issues, and that open conversation led directly to a fix," says Alfonso del Granado, the compliance officer at Ashton Center for Day Surgery.

The fix? Waiting until the patient is wheeled into the OR to start the IV. "We just hang the IV bag over the bed, attach it to the line so the patient is already getting the drip even though the IV isn't started and then, as soon as you wheel the patient in, that's when you start it," says Mr. del Granado. Even when a case is late to start, the ASC still falls well within the 60-minute window. And you can't argue with the results they've seen. "We've had 100% compliance since we started this," says Mr. del Granado.

When You're in the Right, Call Out the Surveyor

Ashton Center for Day Surgery in Hoffman Estates, Ill., knew it had to conduct 3 pre-operative assessments:

  • a general history and physical (H&P) assessment (within 30 days of surgery);
  • an anesthesia assessment (conducted day of surgery); and
  • an evaluation of the procedure being performed (also conducted on the day of surgery).

Under all the guidelines the facility followed, it simply said a competent professional needed to do the 3 assessments, not 3 different people. This was an important distinction.

"Our podiatrists weren't comfortable performing an entire H&P so, in these situations, we'd have our anesthesiologists conduct both the H&P and the anesthesia assessment," says Alfonso del Granado, the compliance officer at Ashton Center for Day Surgery. But a surveyor tried to tell Mr. del Granado this wasn't allowed.

Rather than change the surgical center's protocols, Mr. del Granado challenged the surveyor's assessment. He presented notes showing the center had given real consideration to how it conducted the assessments and that they weren't doing it out of ignorance or lack of interest in patient care. On the contrary, anesthesiologists were conducting the 2 assessments to provide the best in patient care. "I said, "Show where it says I can't do it,'" says Mr. del Granado. "And to his credit, the surveyor listened to my point, and we were able to continue doing it our way."

— Jared Bilski

4. Generating good ideas

PERFECT TIMING Starting the IV antibiotic right as the patient is wheeled into the OR — as opposed to in pre-op — is a proven way to stay within the 60-minute window before surgery.

Have you checked your generator lately? The Saddle River Valley Surgical Center in Paramus, N.J., was cited for not having a yearly fuel and load test for its generator.

"It was a real "wow' moment. This was never brought up during the past 5 surveys I went through," says Mary McIntyre, RN, BSN, CRCST, Saddle River Valley's director of nursing and operations. When the surveyor asked how often the facility tested the diesel fuel in the engine of its generator, Ms. McIntyre said they didn't. Turns out, you need to test or "polish" the fuel yearly to make sure it's pure diesel and hasn't damaged the generator.

Load-testing? The facility wasn't doing that either. Ms. McIntyre not only dug deep into the National Fire Protection Association's guidelines, but also reached out to her generator company for guidance. The generator needed load-testing at a minimum of 30% of capacity.

"If your fuel is watered down and your generator cannot provide power at full load, then your facility isn't as safe as it should be," says Ms. McIntyre. "Yes, the entire process was time-consuming, but however annoying it was at the time, it really did improve the safety of our patients." OSM

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