High-Risk Challenges in ASC Environments

By Susan Annicelli, RN, MA, MS, MSN

The impact of the COVID-19 pandemic over the past 22 months has wreaked havoc within health care organizations across our nation. With lightning speed, the virus gained a foothold on health care organizations as the virus struck with deadly uncertainty and volatility.

Almost overnight, ambulatory surgical centers (ASCs) experienced unprecedented stressors impacting financials, staffing, supply chain, workflow, scope of services and regulatory/statutory requirements. These stressors persist for many ASCs today. Against the backdrop of these challenges, The Joint Commission Ambulatory Health Care (AHC) accreditation process is back functioning at full operation. Our partnership with aligned health care organizations is stronger than ever as we cross the threshold to a dynamic new normal in health care. As persistent as the uncertainty and volatility of the virus is the amazing resolve, creativity and innovation of ambulatory surgical environments to meet COVID challenges head-on. The unyielding efforts to promote quality and safety has been palpable during The Joint Commission post-pandemic accreditation processes.

After the starts and stops of survey activity during 2020, The Joint Commission initiated a virtual platform for AHC surveys in January 2021 and resumed onsite surveys in March 2021. Review of high-risk findings via the Survey Analysis for Evaluating Risk (SAFER) Matrix from within ambulatory organizations during January 1 to September 1, 2021 reveal a similar pattern of observations from pre-pandemic years. High-risk observations are often complex and can pose significant risk in the provision of care, treatment and service.

Top 10 Challenging High-Risk Standards

1. IC.02.02.01. EP2: Implementing infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices and supplies
2. IC.02.01.01. EP2: Using standard precautions,* including the use of personal protective equipment, to reduce the risk of infection
3. IC.02.02.01. EP1: Implementing an organization’s planned infection prevention and control activities and practices, including surveillance, to reduce the risk of infection
4. MM.01.01.03.EP2: Following a process for managing high-alert and hazardous medications. Note: This element of performance is also applicable to sample medications
5. MM.01.02.01.EP2: Taking action to prevent errors involving the interchange of the medications on a health care organization’s list of look-alike/sound-alike medications. Note: This element of performance is also applicable to sample medications
6. NPSG 03.04.01 EP1 Labeling all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups and basins
7. MM.03.01.01.EP8: Removing all expired, damaged and/or contaminated medications and storing them separately from medications available for administration. (Note: This element of performance is also applicable to sample medications.)
8. LD.04.01.05 EP4: Holding staff accountable for their responsibilities
9. EC.02.04.03.EP4: Conducting performance testing of and maintaining all sterilizers. (These activities are documented)
10. EC.02.05.01.EP7: Providing a ventilation system with appropriate pressure relationships, air-exchange rates, filtration efficiencies, relative humidity and temperature in areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust) [Note: Areas designed for control of airborne contaminants include spaces such as all classes of operating rooms, special procedure rooms that require a sterile field, caesarean delivery rooms, rooms for patients diagnosed with or suspected of having airborne communicable diseases (for example, airborne infection isolation rooms, rooms for patients with pulmonary or laryngeal tuberculosis, bronchoscopy treatment rooms), patients in “protective environment” rooms (for example, rooms for patients receiving bone marrow transplants), laboratories, pharmacies, sterile supply/processing rooms, and other sterile spaces]

Avoiding Pitfalls

Navigating a successful ASC accreditation survey is a rigorous process that requires continuous survey readiness. Following are tips to ensure a meaningful survey event:

• Establish a point of contact within the ASC to facilitate the survey process (management of application, communication with the account executive, coordination of the survey event).
• Identify all standards, elements of performance and documentation requirements that are aligned with the type of accreditation survey requested.
• Familiarize staff with the tremendous resources available to ASCs via The Joint Commission secure extranet and dedicated ASC webpage.
• Ensure current and up-to-date documentation of policies, plans, testing logs and all personnel/privileging files.
• Invest in education and familiarization of front-line staff with the survey process. Mock tracers, interviews and rehearsal activity will pay dividends in reducing staff stress during the survey process.
• Anticipate surveyors will utilize a hierarchy approach in assessing infection control requirements with top-to-bottom flow from regulatory requirements to conditions for coverage (CfCs) to manufacturer’s instruction for use to evidence-based guidelines to consensus documents to organizational policy.
• Be prepared to discuss a process improvement initiative that involves data collection and analysis as well as assessment of the culture of safety within the ASC.
• Encourage open and candid communication among staff, leaders and the survey team. Joint Commission surveyors welcome learning about the challenges and opportunities of the ASC from staff at all echelons.

The Joint Commission AHC accreditation process is a not a sprint, but a commitment to excellence overtime. Objectives are clearly defined: validate compliance with standards, provide a meaningful assessment of known and unknown risks and inspire and encourage an ASCs journey to become a high-reliable health care organization. As a committed partner in health care, the accreditation survey is a mainstay in achieving The Joint Commission’s mission to promote safety and quality across all health care domains.

Susan Annicelli, RN, MA, MS, MSN, is a ambulatory field surveyor, accreditation and certification operations, The Joint Commission.