By Lorrie Cappellino, RN, MS, CNOR
It is courageous for an ambulatory surgery center (ASC) to consider undergoing its first accreditation survey, especially while health care organizations, cities, states and our entire country are in the midst of reacting to an international pandemic.
The Joint Commission acknowledges the special pandemic-induced circumstances under which ASCs are currently operating and is mindful of the challenges throughout their survey process. We realize many ASCs are undergoing first-time surveys for a variety of reasons. Some may be newly minted businesses, others have returned to The Joint Commission after changing accreditation courses and others are long-standing ASCs under new leadership. Whatever the reason for the inaugural survey, rest assured that The Joint Commission survey and surveyors are tailored to the ASC’s distinct environment. The Joint Commission is unique in that it accredits organizations in more than 100 countries, providing more than 14,000 surveys, including 1,105 for ASCs annually.
ASC surveys are conducted by specially selected and trained ambulatory surveyors with clinical experience in specialties including surgery center administration, nursing, process improvement, dentistry, surgery, radiology and anesthesia. The goal of every ASC survey is to provide a meaningful, individualized assessment for each ASC setting. Joint Commission surveyors vow to be open and transparent, validate areas in which organizations meet standards, identify leading practices and provide educational opportunities. Additionally, they strive to inspire ASCs to improve patient safety.
The most difficult part of any new process is determining where to start. An accreditation survey evaluates a health care organization to determine if it is meeting important quality and safety standards. So, the best starting point may be to gather and study resources that detail those processes and standards. ASC leaders can begin with The Joint Commission’s Accreditation Handbook for Ambulatory Care which explains the survey process.
Second, request a free trial. It is wise to take The Joint Commission up on our offer to request free 90-day access to the electronic version (E-dition) of Joint Commission standards. This online document is searchable by both chapter and keywords. If your health care organization is seeking Deemed status through The Joint Commission, E-dition’s clear annotations regarding those requirements are helpful.
Third, ask specific questions in advance. ASC leaders may submit questions about standards to experts at The Joint Commission’s Standards Interpretation Group.
Fourth, purchase hard copies of manuals such as the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) and other resources at www.jcrinc.org. Details provided in the manuals offer a wealth of information in an easily accessible format.
Finally, locate online resources provided by The Joint Commission. Search online for helpful resources for ASC management, such as national patient safety goals, The Joint Commission “Perspectives,” and physical environment, environment of care and emergency management planning tools.
At this point, you may be asking yourself, “How do I manage this volume of information?” Delegation often is the answer. Many successful ASC leaders assign “chapter champions” or teams to address critical details of National Patient Safety Goals and each of the 14 chapters of the CAMAC. They then conduct self-assessments and gap analyses before developing and creating processes to ensure they meet standards. ASC leaders also often conduct their own “mock” tracer activities to evaluate processes, identify risks and ensure continuous quality and safety for patients, staff and visitors.
Given the many elements of performance required in the accreditation process, many ASC professionals may wonder what are the most cited observations related to ASCs over the past few years?
Most of ASCs’ commonly cited opportunities to improve fall within the areas of Infection Control and Medication Management.
Below are examples identified as high or moderate risk and likely to cause harm to patients, staff or visitors. These are examples of observations published to organizations’ SAFER matrix at the end of accreditation survey.
Frequently cited infection control issues:
- Lack of documentation regarding sterilizer biologic testing
- Failure to follow manufacturer’s instructions for use regarding mixing chemical disinfectants during instrument decontamination
- Non-compliance with OSHA requirements while transporting used surgical instruments
- Non-compliance of hand hygiene with selected clinical practice guidelines
- Frequently cited medication management issues:
- Failure to label high-alert medications in accordance with organizational policy
- Two or more medications ordered for the same indication (such as pain)
Keep in mind that during survey, The Joint Commission is not focused on minor details like dust bunnies, but rather particulars of heightened importance relevant to an ASC’s specific high-risk areas.
ASC leaders should pay particular attention to the following chapters of the CAMAC manual. They should evaluate the information, line-by-line to ensure every “t” is crossed, and “i” is dotted as they work toward their first survey experience.
The recommended CAMAC manual chapters to review are:
- Infection Control: Sterilizer and high-level disinfection (HLD) management – monitoring of time, temperature and pressure biologic testing; sterilizer/HLD documentation; solutions used for decon/HLD/housekeeping mixed and used in accordance with (IAW) clinical practice guideline (CPG) including temperature and documentation
- Environment of Care: Sterilizer/HLD equipment maintenance and cleaning done IAW MIFU; temp/humidity management, air exchanges/pressure in ORs, decon and rooms where sterile supplies are stored
- Human Resources: Competency assessment for those working in sterilization – ensure the process makes sense, (e.g., document qualified trainers and oversight, how often training/competency is assessed; ensure waived testing is accomplished; using two forms of testing/evaluation; ensure cultural diversity training for all)
- Life Safety: Fire Safety – Pay attention to detail with extinguisher, exit, fire door checks/maintenance; ensure timing/inclusion/post-evaluations of fire drills; include all employees (i.e., licensed independent practitioners) in plan
- Record of Care: Ensure anesthesia and surgeon patient assessments are completed and documented IAW national, state, local and practice/policy guidelines
- Medication Management: Sound processes related to medication order sets, commonly confused and high alert medications, and medication security/avoidance of diversion
My experience working as an operating room (OR) nurse and director for more than 30 years and currently viewing ASCs through the eyes of a Joint Commission surveyor, has shown me that that highly successful ASCs share several common traits when they undergo initial (and subsequent) accreditation surveys.
If successful ASCs have senior leaders in multi-hatted positions, they tend to maintain overall oversight, but coach and delegate portions of responsibilities for CAMAC manual chapter management to trusted mid-level leaders. Regarding identifying risk, effective ASCs leaders encourage and assign current and new staff members to use “fresh eyes” to conduct mock tracers to help identify areas of risk. Additionally, a path to ASC success includes physician involvement. For example, surgeon involvement in the oversight of standing orders, anesthesiologist oversight in determining what items are stored on a crash cart, and most importantly, medical director involvement in governance activities including patient selection criteria, privileging, emergency management decisions and policies as well as involvement in process improvement activities.
Over the past year, The Joint Commission has developed a successful offsite survey process to facilitate accreditation when organizations have not been available for survey due to high countywide COVID rates. Although we know on-site individual patient tracers are crucial to enabling ASC leadership and surveyors to view the big picture of how organizations meet quality and safety standards, the offsite survey process is also extremely valuable. Learning alternate procedures for facilitation of future ASC surveys is imperative.
If you have questions about an upcoming ASC survey or would like to discuss requirements for a first ASC surveyor, please contact your account executive or Pearl Darling, executive director of ambulatory care services at AHCquality@jointcommission.org. Thank you for your continued commitment to quality patient health care during this unprecedented time.
Lorrie Cappellino, RN, MS, CNOR, surveyor, ambulatory health care, The Joint Commission.
