Preparing for your site visit would be a lot easier if you knew what your accreditation surveyor would ask and where he'd look. Here are 10 nooks and crannies recently surveyed hospital, ASC and office managers tell us they didn't expect their surveyors to so thoroughly inspect.

Pre-admission forms
Your history and physical form only needs to cover the body parts relevant to the procedure, a JCAHO surveyor told Christopher Wetzel, RN, BSN, CNOR, the administrator at Hamilton (N.J.) Surgery Center. The surveyor noticed that the center's form detailed all body parts for a physician to review with the patient, which didn't necessarily reflect how the ASC practices.

If your state requires that H&P forms list all body parts, adjust your form to state "not applicable" next to the extraneous parts, says Mr. Wetzel. Don't ignore or fail to check off a section of the body just because it doesn't apply to you, since you must complete all documentation forms, he adds.

A AAAHC surveyor suggested Reston (Va.) Surgery Center eliminate redundancies and condense information on assessment forms to ensure that staff complete them. "If staff tend to leave a certain portion blank or fail to check off a box, see how you can revise the form," says Patricia Dowgewicz, RN, MBA, the ASC's administrator.

AAAASF inspectors recommended that a North Andover, Mass., office-based plastic surgery center use pre-printed forms, as they often double as a checklist that help staff remember details for patient assessments. "We've created checklists for admitting patients, discharging patients and anything applicable in between," says Patrick Marasco, MD, FACS, owner of the Plastic Surgery Center.

Credentialing
Specify who provides references when credentialing physicians, the JCAHO surveyor told Mr. Wetzel. When credentialing a GI doctor, get a reference letter from a peer - another GI specialist who can attest that the physician has the skills to perform in this specialty. Verification letters from where a physician practices must also state that he can perform within a specialty. "Don't create a blanket letter that says the doctor is a good doctor," says Mr. Wetzel.

While touring the outpatient surgery department at Saint Anne's Hospital in Fall River, Mass., the surveyor asked staff rather than managers about their credentialing processes and how competency to perform procedures is determined. "He wanted to ensure that staff know what to do if a surgeon they don't know is on the schedule," says Carole Billington, RN, BSN, CNA, BC, the director of surgical services, endoscopy and cardiovascular at Saint Anne's.

Staff have access to the hospital's credentialing book and know to verify - if need be - with the medical staff office. Also, a physician who doesn't appear in the credentialing book won't have a preference card for the procedure, a red flag.

Competencies
You'll probably have to explain to your surveyor how you assess and assure that physicians are competent to perform conscious sedation, says Mr. Wetzel. You might include an "ACLS-certified" box to check off on the letter you issue to validate a practitioner's skills.

What Jonathan Freed, MD, owner of Freed Plastic Surgery in Auburn, Calif., found interesting on survey day was that it wasn't enough to show the AAAASF surveyor his list of ACLS-certified staff. The surveyor wanted to see copies of the ACLS cards.

Since the JCAHO likes to see data portrayed in graphs and spreadsheets, the surveyor liked that staff measure pre-operative and post-operative competency testing by graphing how the staff performs on annual in-servicing with pre- and post-tests, says Gina Espenschied, RN, SN, CNOR, Hamilton Surgery Center's clinical manager.

Drug abbreviations
Get ready to talk about your facility's policy on unapproved drug abbreviations. Create a standard list (approved by your medical executive committee and governing body), as your surveyor will ask to see your list to compare it with documentation in medical records.

"Audit your records regularly to keep track of compliance, and that means planned and unplanned audits," says Ms. Dowgewicz.

Some caregivers are used to writing down "cc" instead of "ml," so continually educate them on the use of proper dosage abbreviations, says Mr. Wetzel.

At Saint Anne's Hospital, the surveyor asked staff how they treat misused abbreviations, says Ms. Billington. The pharmacist audits physician medication orders for unapproved abbreviations and shares results with the medical staff.

Policies
Hamilton Surgery Center's surveyor didn't want to just page through its policy manuals. He asked staff whether they performed procedures according to the center's policy, comparing their explanations of a process to the policy. Ms. Dowgewicz's surveyor suggested that when revising pediatric patient policies, staff should inspect safety issues in all areas where a child is treated. The process revealed that outlets in the pre-op area were without electrical safety caps.

Patient privacy
When checking for HIPAA compliance, the surveyor at Hamilton Surgery Center said to keep clinical patient information in separate files from physician files, says Mr. Wetzel. Why? If a patient should sue a doctor, and the plaintiff's lawyer asks for the credentialing record for that physician, any patient medical information found in the credentialing file would be in violation of HIPAA.

Reston Surgery Center's surveyor wanted to know the ASC's policy for handling vendors in the OR who may assist the surgeon with new equipment. It didn't have one. Patients as part of informed consent must sign off that they agree to have a vendor there, says Ms. Dowgewicz.

Mr. Freed keeps patient charts in an area behind the reception desk that is obscured from patients' views. He installed screens on the computers in the front office and OR that shield what's on the screen. His surveyor noted that he liked that, as well as the staff's practice of addressing patients by first name only and leaving only minimal patient information on answering machines, says Mr. Freed.

Surgical time out
To verify who participated in the time out, Reston Surgery Center's surveyor suggested that it add to the time-out area of the operative form a check-off box for the surgeon, circulating nurse, scrub technician and CRNA.

Hamilton Surgery Center's surveyor was pleased to see, when he went into the GI suite or OR and asked the nurse to talk him through the process, that staff responses were consistent, and that they followed the center's policies and JCAHO's protocols to prevent wrong-patient/site/procedure surgery, says Ms. Espenschied.

Governing body
The surveyor told Ms. Dowgewicz it does little good to track hospital admits, medical errors and other key issues if you don't report this data to the medical executive committee and governing body. A remedy: Include on meeting agendas a follow-up section to ensure managers report data to decision makers.

Surgical drugs
Avoid ambiguity with range orders. A chart that says, "Give between 2mg and 10mg of morphine" puts too much onus on the nursing staff to determine the proper range order when it's the physician's duty, says Mary Ellen Robbins, RN, the director of surgical services at Bert Fish Medical Center in New Smyrna Beach, Fla.

The JCAHO surveyor wanted to see a rationale for range orders, says Ms. Robbins. For example, a report should read, "Pain scale 0-4, give 2mg every three minutes. May repeat up to 10mg. Pain scale 5-10, give 4mg every three minutes. May repeat up to 12mg."

While tracing a patient who went to the endoscopy suite at Saint Anne's, the surveyor observed how the nursing staff accessed medicines, how they handled waste, and whether the crash cart was available and secured, says Ms. Billington.

Penmanship
Surveyors won't tolerate illegible medical records and physician orders. If the surveyor picks up a chart and can't read the handwriting, he might turn to whoever is nearby and ask that person to read the chart, just to make his point.

Throughout the survey at Saint Anne's Hospital, the surveyor scanned all written documentation for illegible writing, and when in doubt, also asked the closest person if she could read the handwriting. "If someone could read it, he'd say, ?What if I was new here?'" says Ms. Billington. The surveyor shared with Ms. Billington two cures for illegible handwriting: asking physicians to print or investing in EMRs.

Human touch
Most surveyors represent organizations that have no desire to see your facility fail. Rather than viewing surveyors as imposing or dictatorial opponents, consider them as partners and educators in the survey process. Especially now that you know what to expect.