that obviously does not apply to your ASC and put your name on it. That will not fly with surveyors.” What they are looking for, Allison says, are details specific to the ASC and its location. “Surveyors want to see that the haz- ards addressed make sense for your county and you clearly explain how your ASC will respond. They want to see that you have identified who will coordinate the response and who will be delegated authority should that per- son be unavailable. . . .” They also want to see that you have determined a pri- mary and alternative means of commu- nicating with local authorities during an emergency, she adds. The rationale behind that high

level of detail, she explains, is to encourage everyone to work together in a collaborative way and make sure there is a coordinated response dur- ing an emergency.

Practice Makes Perfect

Completing documentation will help your ASC prepare for an emergency but only take you so far, Kilgore says. “We performed our risk assess- ment and looked at areas of weak- ness. For us, what it boiled down to was doing scenario-based drills.” You cannot effectively deter- mine whether your plan will prove successful under fire unless you put it and your staff to the test, Alli- son says. That, she says, is the pur- pose of performing the two required annual emergency preparedness drills. “While there is great value in facility-based and tabletop exercises, strive to participate in community drills,” she advises. Local communi- ties are increasingly hosting meetings to put together their disaster drills, and these are routinely open to all those facilities affected by the federal requirements. “Surveyors want to see that you have consulted with your local authorities and are playing an

Bring in local authorities to educate staff on scenarios such as active shooters. Get involved in your state’s ASC association.”

—Jeanne Desautels, United Surgical Partners International

active role in community prepared- ness,” Allison adds. Whenever you participate in any type of drill, take the time to assess your performance and look for oppor- tunities to improve, Kilgore says. “We found that when we try to simu- late the response experience, we are amazed by what we learn.” During one fire drill at Kilgore’s

ASC, staff were assigned to play the roles of patients and family mem- bers. “We put one of our employees

acting as a patient on a stretcher and wheeled this patient down a ramp and away from the building. The way our ramp is set up, and with the momen- tum behind that stretcher, we dis- covered it took two nurses to control that stretcher and keep it from flying across the parking lot.”

Kilgore says this fire drill shed light on another important prepa- ration component previously over- looked. “There were questions about the location of our shut-offs, such as


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