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Changes in ASC Survey In late November, The Joint Commission announced it was making adjustments to its ASC survey process effective January 2017. If your ASC is accredited by The Joint Commission, it is important to understand the changes made, including whether they apply to your ASC. Even if your ASC is accredited by another orga- nization, it is worthwhile to understand these changes as your accrediting body may be implementing similar changes soon.


Here are 10 points to know about The Joint Commission’s ASC survey changes.


1 The changes only affect Medicare-deemed ASCs. If your ASC does not use the Medicare-deemed option for your Joint Commission survey, the changes will not apply to you. This change was made to be compliant with instructions from the Centers for Medicare & Medicaid Services (CMS).


2 The changes do not apply to all Medicare-deemed ASCs. Medicare-deemed ASCs with low patient volume will not experience a change to the typical one- surveyor, two-day Joint Commission survey event. About one-third of Joint Commission customers will not be affected.


3 Affected ASCs will see one of two changes. If an ASC has larger patient vol- ume, it can expect one or two changes to the survey experience: adding one surveyor day (one surveyor for three days) or adding a second clinical surveyor (two surveyors for two days).


4 The Life Safety Code component has no changes and will remain a one-day addition of one Life Safety Code specialist surveyor, barring extenuating cir- cumstances that require additional time.


5 De novo ASCs will see no change. New ASCs will experience the “traditional” survey experience of a single surveyor for two days plus the Life Safety Code specialist surveyor for one day.


6 The revised survey process should provide ASCs with more opportunities for education and improvement. For ASCs that will now be visited by two clinical surveyors, they will receive twice the insight.


7 One of the top requests from customers is consistency in standards inter- pretation or consistency from surveyor to surveyor, one survey event to the next and when they call The Joint Commission for answers to questions. Two clinical surveyors onsite together should help with that consistency, with the ability, in private, for surveyors to bounce their observations off each other.


8 Busy ASCs will welcome the reduction in number of days surveyors are on- site, for example, a change from one surveyor for three days to two surveyors for two days. Take the word of our Joint Commission customer who tells her ASC’s story in AmBuzz: https://www.jointcommission.org/ambulatory_buzz/ asc_admin_view_of_on-site_survey/


9 Survey fees for Medicare-deemed ASCs will be adjusted, if necessary, to reflect the changing number of surveyors and length of the survey.


10 The CMS guidance for survey changes does not apply only to The Joint Com- mission. CMS expects the same guidance to be adhered to by the other ac- creditation organizations that survey on its behalf. If these organizations have not made these changes yet, that may be happening in the future.


If you are interested in learning more, check out The Joint Commission’s “Take 5” podcast focused specifically on the 2017 changes for deemed ASCs. Link: http://traffic.libsyn.com/jointcommission/Take_5_ASC_2017.mp3


Also see AmBuzz on CMS changes: https://www.jointcommission.org/ambulatory_ buzz/five_things_you_need_to_know_2017_survey_medicare_deemed_ascs/


12 ASC FOCUS SEPTEMBER 2017 |www.ascfocus.org


Enhance Relevancy of Accreditation Through discussions with accred- ited organizations and stakeholders, The Joint Commission found that the on-site survey process was key to the perceived value of the accreditation process. Through simplification and survey changes, it increased the survey focus on patient safety and risk man- agement. The goal was to help orga- nizations clearly understand the survey findings and create plans to mitigate identified or potential issues. In the post-survey process, The Joint Commission has redesigned the Evidence of Standards Compliance (ESC) form to help organizations bet- ter describe the critical aspects of their corrective actions. The changes are aimed at streamlining, improving and increasing the relevancy of the post- survey process for accredited ambula- tory care organizations. A critical improvement to the post-


survey process is the changes around the clarification of a survey finding. The new process allows for clarifica- tion to happen during the survey—in real-time—so both the surveyors and the organization can come to a reso- lution quickly. This makes the pro- cess efficient for everyone involved because the ASC can clarify the matter while the surveyor is still on-site. In addition, The Joint Commission has initiated a change that will allow the organization being surveyed to par- ticipate in certain calls with the surveyor to The Joint Commission’s Standards Interpretation Group (SIG) during the survey. This allows questions or con- cerns to be discussed and resolved with complete transparency.


Enriching the Accreditation Process with Innovation and Transparency Beginning this year is one of the biggest improvements The Joint Commission has made to the survey process: the Survey Analysis for Evaluating Risk (SAFER™),


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