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Joint Commission, AAAHC Experts Offer Simple Hacks to Improve Accreditation Surveys
By: Carina Stanton | Contributing Editor
From the most cited deficiencies to best practices that will impress surveyors, get the inside track on how to ace your next survey.
A new year means a new focus on survey success. Beyond maintaining certification and accreditation, surveys help outpatient surgery centers dial in on their safety and quality performance. The survey process can lead to better outcomes, more satisfied patients and, ultimately, more income to sustain the center.
Cultivate a survey mindset
To improve performance, ASC leaders must emphasize a survey mindset every day, says Cheryl Pistone, clinical director at the Accreditation Association for Ambulatory Health Care (AAAHC). To that end, AAAHC stresses its 1095 Strong philosophy, which helps ASCs focus on survey readiness all 1,095 days of the accreditation term. “We expect organizations to achieve continuous compliance, which also better prepares them for the next survey cycle,” says Ms. Pistone, who suggests three essential ways to stay survey-ready every day:
- Integrate a commitment to patient safety into the culture of the organization
- Apply current clinical practice guidelines, and
- Comply with state and federal guidelines.
ASCs must self-assess to identify and address gaps in these practices before a surveyor visits, Ms. Pistone recommends that ASCs perform a self-assessment using AAAHC standards. With assessment data, an ASC leader can implement corrective actions and monitor compliance with policies and procedures to improve chances of achieving a positive survey outcome.
While assessing for standards compliance and improvement, it’s also valuable to be aware of areas that surveyors commonly cite as shortcomings across all ASCs.
Julie Lynch, director of AAAHC’s Institute for Quality Improvement, says AAAHC’s deficiency data for last year revealed ASCs’ most frequently failed survey elements were:
- Emergency preparedness
- Credentialing and privileging
- Infection prevention and control
- Documentation management, and
- Quality improvement.
“The COVID-driven labor shortage that plagued the healthcare space continues to impact facility operations,” notes Ms. Lynch. “Administrators should prioritize these critical areas to ensure ongoing safe, quality care.”
AORN recently updated guidelines for manual high-level disinfection and safe environment of care. Understanding the latest evidence-based recommendations in these guidelines can help ensure your facility’s practices reflect the latest evidence.
Here’s a quick look at several of the many updates from each guideline that surveyors could be looking for.
From the AORN Guideline for Manual High-Level Disinfection:
- Incorporate ergonomic features to address personnel discomfort during manual cleaning and processing methods.
- Assist decontamination personnel by providing information during the handover from the transporter, such as the time that point-of-use treatment was completed.
- Use a clean borescope to visually inspect accessible channels of the device before high-level disinfection.
From the AORN Guideline for Safe Environment of Care:
- An interdisciplinary team should develop and implement a perioperative clinical and alert alarm management plan.
- A comprehensive occupational slip, trip and fall prevention program should include elements such as an assessment of hazards, a review of incident data and more.
- Fire-prevention should address the specific risks identified by the perioperative team during a fire risk assessment. Learn more with the new AORN Fire Risk Assessment and Prevention Algorithm in the guideline.
Explore current AORN guidelines and implementation resources at aornguidelines.org.
Focus on infection prevention issues
Infection control and environment of care are frequently cited for deficiencies during ASC surveys by The Joint Commission (TJC), says Elizabeth Even, RN, senior assistant director, standards interpretation group operations and quality assurance for TJC.
She notes, however, that it is possible to reduce the risk of survey citations in these areas with these actions:
Improve basic infection control practices. Deficiencies with an ASC’s infection prevention and control plan were major issues that Joint Commission surveyors cited in 2023. These common citations fall under Joint Commission standard IC.02.01.01 EP2 and elements of performance, which Ms. Even describes as the cornerstone of an effective infection prevention program. Several infection prevention opportunities often scored low in ASC surveys:
- Proper hand hygiene
- Disinfecting medication vials and IV hubs prior to medication administration, and
- Availability of proper personal protective equipment for staff.
Improve high-level disinfection and sterilization for surgical instruments, equipment and other critical devices. Joint Commission surveyors frequently cited ASCs last year for inadequacies in this area. Ms. Even says ASCs should ensure instruments are in good condition and sterilized according to validated manufacturer’s instructions. She says ASC leaders can improve these practices by critically inspecting all areas that reprocess instruments. They should also ask themselves these questions:
- Are we following the manufacturer’s instructions for use?
- Are staff educated, trained and competent to perform their responsibilities?
- Do staff have all necessary resources to complete their job responsibilities?
- Is there sufficient oversight of reprocessing?
Maintain up-to-code environment of care requirements. “All of these infection control activities happen within a physical space that also needs to be maintained,” says Ms. Even. Frequently cited issues within the environment of care during Joint Commission surveys last year included:
- Mapping the distribution of the utility systems
- Inspecting the emergency power supply systems, including all associated components and batteries
- Producing documentation that supports all of these requirements.
For example, standard EC.02.05.03 EP28 was scored 156 times from January 1, 2023, to December 1, 2023. It requires documentation of all maintenance, testing and inspection activities under each entire standard and element of performance as it applies to each center, Ms. Even says. She adds this may include oversight of smoke detectors, fire alarms, automatic sprinkler systems and other facility safety features.
Here are five steps that can help any ASC score well on its next AAAHC survey:
• Stay up to date with compliance measures. Regularly monitor and review all applicable federal, state and local regulations related to health care and ASC operations.
• Review previous deficiencies through your organization’s quality improvement program. Ensure a heightened focus on your top deficiencies noted in previous surveys. Implement corrective action and monitor outcomes to ensure sustainability.
• Conduct a mock survey against current accreditation standards. This self-assessment can help identify and address potential gaps before the actual survey occurs. It is also a valuable tool to reinforce a compliance culture and can help your team become more familiar with the survey process to reduce “day of survey” nervousness and build confidence. Keep your governing body apprised of the survey-readiness process and any plans for corrections.
• Encourage open and transparent communication. Ensure that all staff members are informed of policies and procedures. They should be actively engaged in quality improvement and compliance. Effective teamwork can contribute to a smoother survey process and ongoing compliance.
• Provide ongoing staff training and education. Ensure competency in specific roles, responsibilities and compliance requirements. Document staff training and maintain records of individual competencies to ensure all staff are aware of and follow current best practices and guidelines.
Show your work
During a survey, leaders and their team members should engage and participate. Consider the thoroughness of the necessary information and documentation you are sharing, and lend context to less apparent or difficult-to-find policies and processes within your organization, Ms. Even advises. “This is an ASC’s opportunity to highlight all of the great work that has been done since its last survey and to gain insight into possible solutions to issues that have arisen since then,” she says.
This is an ASC’s opportunity to highlight all of the great work that has been done since its last survey and to gain insight into possible solutions to issues that have arisen since then.
Elizabeth Even, RN
One important tool to help leaders prepare for showcasing their facility to surveyors includes The Joint Commission’s 2024 Ambulatory Care Accreditation Survey Activity Guide. It lists much of the required documentation surveyors request. “Having this information and documentation ready and available immediately upon request is one way to make a positive impression on the survey team,” Ms. Even says.
In addition to documentation, providing key experts to present or answer questions helps ensure the survey team is correctly understanding and interpreting information presented to them, she adds. “Giving your experts a chance to engage with surveyors is a fantastic way to present a full and accurate picture of an ASC and everything that goes into the care delivered,” says Ms. Even.
Remember that surveyors must conduct a survey according to what they read, what they see, and what they are told, she adds. “Focusing on providing information that positively represents all three of these areas is a great way for healthcare organizations to highlight their best practices to The Joint Commission survey team,” says Ms. Even.
Don’t hesitate to ask surveyors how you can do better. “Surveyors hold a wealth of knowledge not only about requirements ASCs must meet, but also about how similar organizations comply with common issues and opportunities,” says Ms. Even. OSM
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