When I check in with my husband after completing an accreditation survey, he tries to guess which deficiencies I found. "Was it safe injection practices or the IFUs this time? I bet it was the IFUs." He's not even in health care, but he's repeatedly heard me mention the same 7 standards that administrators and OR managers are almost always surprised to learn they're not following.

1. Disaster prep

If you're seeking CMS accreditation, you need to be aware of these new standards on disaster preparedness. I've performed many CMS surveys since it went into effect in November of last year and found early on that many of you aren't aware of these requirements. Most surgery center leaders are accustomed to thinking that we're not involved with disaster prep, but CMS has changed that. In the event of a large-scale emergency situation, like the mass shooting in Las Vegas, Nev., hospitals might not have the resources or personnel to accommodate a huge influx of patients. So the new standards for CMS accreditation require that your surgery center be prepared if the state or federal government issues a state of emergency and directs patients to your facility. I'll highlight a few here and the rest you can find in a link I've provided to CMS Emergency Preparedness Guidelines and Notes for the Surveyor (osmag.net/H2wmkj).

• You have to be able to shelter in place with patients and staff. This means you must have access to potable water and snacks, and a place for people to stay for extended periods of time if that becomes necessary.
• You must have a way to track your staff in case they have to go with a patient temporarily to another facility.
• If your governor or the President issues a waiver for additional healthcare professionals to come help you, you have to be ready to handle them.
• You have to coordinate with your local emergency management association to let them know what resources you have at your facility for emergencies (the number of beds, wheelchairs and stretchers, for example).

2. Safe injection practices

Are you still filling your syringes from a multi-dose vial in patient care areas? And I don't just mean the OR. You shouldn't be. Both the CDC and CMS say that's not safe practice. So if you have a multi-dose vial of 1% lidocaine that you want to use on more than one patient, you'll have to fill your syringe in a designated medication prep area that is away from anywhere that you do patient care in order to meet this standard. I've generally been able to find a dedicated space in even some of the smallest facilities. Alternatively, you can treat multi-dose vials as single-dose vials. Also remember that any medication drawn into a syringe is good for only 1 hour.

3. Sound-alike, look-alike drugs

Some facilities don't think they have sound-alike/look-alike drugs, but my experience has shown that most do. The Institute for Safe Medication Practices (ISMP) has a huge list of these drugs. I recommend looking at that list and comparing it with a list of drugs in your facility. You can place brightly colored stickers on the drugs that show up in both lists or physically separate the drugs that look or sound alike. People are often in a hurry and you just want to help them in their timeliness, while also taking out the variables that can lead to patient harm.

Here are some other tips to keep your sound-alike/look-alike drugs straight during every stage of the patient care process:

• Highlight the sound-alike/look-alike drugs with a yellow marker when they are stored.
• When brand names sound alike or look alike, order the medication by both the brand name and its generic name.
• Always print or type the names of medications. Use preprinted labels if you can.
• Include why the drug was prescribed in the EMR so the nurse can determine the purpose of the medication before administration. In most cases, the drugs that sound alike or look alike are used for different things.
• Only accept verbal or telephone medication orders if necessary and always repeat the orders back to the prescriber.
• Let your patients know if they'll be taking a sound-alike/look-alike drug so they can be vigilant in reading the labels on their medications.
• Tell your patients to immediately report any changes to the size, color or smell of their medications to the pharmacist, prescriber or healthcare provider.

Keep your staff informed of the potential for errors and if any errors actually occur.

4. High-alert medications

Did you know that insulin is a high-alert medication? Did you also know that you need to keep a list of your high-alert meds? The ISMP also has a list of them you can reference (osmag.net/S3zfYJ). You also have to store these medications in a way that decreases the chance of misuse. This can be as simple as putting a high-alert sticker on the medication or even storing them in a big red box.

5. IFU access

This one is a common one. For all of your instruments and equipment, you must be able to access the instructions for use (IFU). I remember one facility I surveyed, I asked them where they kept their IFUs and they looked at me like, "What are you even talking about?" If you want to impress your surveyor, show her your notebook of IFUs for your facility or, even better, show them that you have access to onesourcedocs.com. OneSource has access to every manufacturer's IFU, and if they don't have it, you can request via email that they get it. But if you can't swing that, just ask your sales rep for it. And don't just trust what the vendor tells you about using the instrument. Ask for it in writing. Just because 2 instruments are similar does not mean they have the same sterilization process.

6. Impaired and incapacitated staff policy

What will your facility do if one of your surgeons has chest pains, faints or becomes unconscious during a procedure? What about if one of your nurses comes to work with alcohol on her breath or appears to be under the influence of drugs? Many facilities believe their impaired and incapacitated healthcare professional policies apply only to the surgeon, but you need these policies in place for anyone in your facility, and particularly for those on your surgical team. The policies that are clearest specifically address each healthcare professional and what you should do when they are impaired or incapacitated.

7. Dismissing a patient policy

I once had a belligerent patient — screaming, yelling and beating on the counter. So I called her doctor and he said, "Tell her she is not having her case here today. She is cancelled and tell her to call my office." I informed her and sent her on her way — out of the facility. Thank goodness we had a protocol for this, otherwise I wouldn't have known how to discharge that patient from our facility.

There are a few common situations where you'd need to dismiss a patient from care and you need a policy and procedure to address each one. Some of those situations include patients who are not following the physician's prescribed plan of care, patients who fail to respond to financial requests or to follow your facility's policies surrounding patient responsibility. So it's best to include representatives from admissions or the business side of your facility along with the medical director. How are you going to dismiss the patient? Will you write a letter or call them? How and when will you notify their physician of the decision?

If you live long enough, you're going to run into these situations. You just need to be prepared. And that's what these requirements are all about, being prepared so you can take care of your patients and staff — no matter what happens. OSM