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For passing accreditation surveys, documentation key

Joyce McIntyre, the OR Coordinator for Potomac Valley hospital in Keyser, W.V., says that when The Joint Commission surveyed her facility last January, surveyors paid especially close attention to whether OR personnel had regularly updated patients’ history and physical records prior to surgery, completed pre-anesthesia assessments, and checked temperature and humidity. Each of those checkpoints can be confirmed during a survey with proper documentation.

Though McIntyre’s facility maintains proper temperature and humidity in the OR, “We got dinged because the dates of checking for both were not completed.” Potomac Valley Hospital passed the accreditation survey, but experts agree that maintaining proper documentation is key in minimizing survey stress.

Accreditation for hospitals and ASCs is essential – it ensures proper Medicare and Medicaid reimbursement, is necessary for a license to operate for most ASCs, and provides reassurance to patients that the facility has met certain standards.

Most ASCs and hospitals provide care to Medicare beneficiaries and rely on reimbursement as a source of revenue. To receive Medicare reimbursement, those facilities must meet standards set forth by the U.S. Centers for Medicare and Medicaid Services (CMS). Facilities achieve certification by passing regular surveys conducted by a CMSdeemed eligible organization. Eligible accrediting organizations for hospitals include The Joint Commission (TJC) and Det Norske Veritas (DNV) Healthcare, Inc., which received deeming status in 2008. Options for ASCs include TJC, the Accreditation Association for Ambulatory Health Care (AAAHC) and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).

In most states, ASCs must meet specific requirements to obtain a state license, including passing inspections conducted by a CMSdeemed accrediting body. A surveyor will visit the ASC on a regular basis to verify that it meets established standards. With revenue and reputation on the line, helping your facility prepare for a survey might sound daunting.

But the preparation process – and the jitters that sometimes accompany it – can vary greatly depending on your facility and the accrediting body you choose. CMS mandates that surveys are unannounced, but some organizations survey more often than others. Facilities seeking TJC accreditation are subject to an unannounced survey every three years, while DNV-accredited hospitals conduct annual visits. Both AAAHC and AAASF conduct CMS-deemed unannounced surveys every three years. Both organizations also conduct intermittent nondeemed status surveys that are scheduled in advance to ensure the maintenance of standards.

“[Non-deemed] AAAHC surveys are arranged to the mutual convenience of us and the organization – preferably when the key personnel are there and the AAAHC surveyors can observe a procedure,” says Geoffrey Charlton-Perrin, Marketing Manager for AAAHC.

Preparation techniques

Thomas Barton, RN, MSN, a field director for TJC, offers some ways to ward off the jitters of knowing a surveyor may arrive at any time, and to ensure perpetual preparedness. “The best way for OR nurses and scrub technicians to be prepared for a survey is to be familiar with the Joint Commission standards that pertain to the OR, as well as the Association of periOperative Registered Nurses’ (AORN) standards and recommend practices,” he says. “We will often ask the OR staff what is AORN’s position on an issue. This is how we sometimes make an interpretive decision on some of our standards.”

For example, AORN establishes parameters for humidity and temperature in an OR suite. “So if we ask the OR staff how they determine what the range for temperature and humidity should be, they might answer that they follow AORN guidelines, or they go with what CMS tells them.”

“AORN’s recommended practices for perioperative nursing represent what is believed to be optimal and achievable perioperative nursing practice, based on the highest level of evidence available,” adds Lisa Spruce, RN, DNP, ACNS, ACNP, ANP, CNOR, the director of Evidence-Based Perioperative Practice for AORN. “They are intended to describe excellent perioperative nursing practices, promote patient and health care worker safety, and guide policy and procedure development in surgical and invasive procedural settings.”

According to Nancy Jo Vinson, RN, BA, CASC, a surveyor for the AAAHC, planning for an AAAHC accreditation survey starts with making sure you have the appropriate and current AAAHC Accreditation Handbook. “This is the blueprint from which to build your foundation for survey success. Keep in mind the timeframe of your survey and your type of facility, and give yourself sufficient time to read and understand the handbook. And remember to establish a realistic timeline to complete your project, including submission of the application.”

Inspection or consultation?

While some nurses view surveys as a kind of inspection, Barton stresses that this isn’t how the Joint Commission sees it. “The goal of our survey is to ensure that quality and safety are integrated into everything that’s done in the facility, whether this is in the OR, pre-op or the recovery room,” Barton says. “It’s not an inspection—there’s a lot of interaction with the staff in terms of education and consultation.”

Charlton-Perrin says the AAAHC takes a similarly consultative approach. “Ever since the inception of AAAHC, we have conducted our surveys by your peers (physicians, nurses, medical directors and administrators etc.) who bring a more understanding attitude to the process because they inhabit the same world on a day-to-day basis,” he says. “In our post survey responses, organizations continually remark that they ‘learned so much’ because the AAAHC surveyors were helpful and offered suggestions on how to improve the care delivery process.”

In December 2009, Hoag Hospital of Newport Beach, Calif., signed on with DNV Healthcare, Inc., in conjunction with the opening of a new Hoag campus in Irvine. Marilyn Lang, director of patient safety and regulatory compliance, told Medical Dealer she preferred DNV’s less dogmatic approach, in a January 2011 article about accreditation. DNV assigns each hospital a survey team, which will return to complete an annual survey for three consecutive years.

After the initial survey, hospital employees are familiar with the team, and team members can be contacted throughout the year. “TJC’s idea is just different,” Lang said. “The surveyor is just there as a surveyor. You can send inquiries to a certain address, and they have a group of people that will answer questions, but you don’t develop that relationship.”

Hoag also prefers the regularity of annual DNV surveys. “It keeps you on your toes,” Lang said. “It doesn’t become a dress-up party where every three years you’re dressing things up for the survey.” But TJC may be trying to soften their image – for ASCs, its approach is now more in line with the consultative approach of the AAAHC. The Joint Commission’s Barton encourages OR staff to be as open and transparent with surveyors as possible. “If you’re having any problems, let us know and let’s talk about it. We can usually offer ideas and suggestions based on how other facilities have addressed similar problems and issues.”

Common surveyor expectations

Amy Sinder M.S., who is the administrator at the CBC Surgery Center in Crown Point, Ind., says TJC surveyors “expect everyone to follow our facility policies, and for those policies to be in line with TJC standards. The surveyors check to make sure we are testing and cleaning our equipment per the manufacturer’s guidelines and that we are all hand-washing appropriately. They also want to make sure we document our narcotic usage, store narcotics appropriately, and complete a timeout prior to surgery, as well as an additional timeout prior to an anesthesia block if a block is performed.”

“Surveys are almost always a very stressful time, so I remind my staff that they do not need to know the answer to every question,” Sinder says. “It is perfectly acceptable to say, ‘I’m not sure. Let me find Amy and ask her, or look it up in our Policy & Procedure Manual.’” Sinder says she gives handouts and educational materials throughout the year to all staff members to help them be better prepared, and arranges for a consultant to visit once or twice a year who updates staff on important changes made by TJC.

According to R. Peter Rossi, BS, RN, Nurse Manager Surgical Services at Halifax Regional in Roanoke Rapids, N.C., the most common things surveyors check for at his facility are patient identification, timeouts, medication administration and secured storage, traffic patterns, chain of custody for tissue storage and pathology specimens, product expirations, immediate use sterilization, disaster and fire plans, clutter and cleanliness.

“In my role as nurse manager, I help prepare our staff for surveys by conducting mock surveys, scheduling disaster drills, auditing documentation and reviewing all policies and revising them when necessary. Don’t wait until right before your expected date of survey to start looking at what your responsibilities are. Maintaining standards readiness needs to be a continuous routine.”

Joyce McIntyre, the OR Coordinator for Potomac Valley Hospital in Keyser, W.V., says that when her facility was surveyed last January, the surveyors paid especially close attention to proper documentation. “Also, endoscopes were a big thing—our hanging conditions were criticized. The endoscopes couldn’t be touching anything. They also made a big deal out of laryngoscope blades—ours had been cleaned, but not packaged.”

“My role in the survey process is to support the management team and staff by identifying areas needing improvement, mitigating deficiencies before review, preparing the staff for the survey process, and reinforcing staff knowledge,” says Maureen (Ren) Scott-Feagle, MSN/Ed, RN, CNOR, Clinical Educator for Surgical Services at University Medical Center in Las Vegas. “Not only do I survey the environment of care, but I also search for deficiencies in documentation, forms, and policies and procedures.”

Scott-Feagle says her facility commonly encounters documentation errors generated by physicians, such as failure to document date/time, use of non-approved abbreviations, and failure to chart post-op findings in detail. “On the nursing side, medication expiration dating and security, along with cleaning and disinfecting of medical devices used on multiple patients, are common areas examined by surveyors. They will also scrutinize any discrepancies between policy and procedure, so be sure you’re ‘walking the talk.’”

She stresses the importance of allotting sufficient time for survey preparation based on the size of your facility. “And strive to reduce clutter—identify your ‘supply and form hoarders.’ These folks can inadvertently generate a plethora of expired items and forms in patient rooms, cupboards and cabinets.

“A clean, organized presentation of your patient care environment will make the survey process less stressful and more productive for everyone,” says Scott-Feagle.

Maintaining paperwork

One common theme that seems to emerge from this kind of feedback is that maintaining the proper documentation and paperwork is one of the biggest challenges to a successful accreditation survey. Tamar Glaser, RN, an American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) Medicare Surveyor and the CEO of Accreditation Services, Inc., says her company recently developed a software program that helps ASCs in this area (

“In my extensive nationwide survey experience, I kept seeing the same deficiency: Facilities were providing great patient care but were facing challenges in maintaining the required documentation for their accreditation and state regulations.”

“Survey preparation is fluid and must be continuous,” adds Vinson. “During each survey, surveyors may spend more time on one component than another. Therefore, don’t assume that just because an issue is not identified at one survey that it will be correct at the next survey.”



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