ments listed. So, involving the staff is key as they are actually the ones work- ing with the patients and know what is and is not being followed. We presently use an electronic health care compliance and regulatory training system. Staff are expected to complete annual competencies like compliance/Health Insurance Porta- bility and Accountability Act of 1996 (HIPAA)/Occupational Safety and Health Administration (OSHA)/fire training/drug testing policy and then ones that are related to their areas of expertise: lifting and positioning, fluo- roscopy, drugs, sterile technique, etc. In addition, we require basic cardiac life support (BCLS), advanced car- diac life support (ACLS) and pediat- ric advanced life support (PALS) for our nurses. I would estimate that staff spend at least 20 hours a year working on competencies or attending in-ser- vices. The practice has a new training session that I need to schedule on vio- lence in the workplace.

My medical director is also very good about addressing any compli- ance/policy violation issues with his peers. Like most surgery centers, we have

great staff who work hard and get along well, and as a result, we receive excellent patient satisfaction scores. The staff is aware of policies and if something does not seem quite right, they are not afraid to bring it to some- one’s attention. This is essential if you are going to practice safely and not be in violation of some policy. Our sur- gery center opened 12 years ago, and I still am asked questions that I do not know the answer to.

How do you prepare for a survey? PAGE: I start early, reminding staff that I will soon be filling out the appli- cation for re-accreditation, but I also try to pass on information throughout the year that they might need to know. The PACU/OR director assists me as we both go to the ASCA annual conference



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and come back with details on what sur- veyors are looking for and what surgery centers are being dinged on. As time permits, we attempt to review policies or get an anesthesiologist/pharmacist,

etc., to review the policies that pertain to their area.

I stress the need to be tidy around here. Supplies can start looking very disorderly when staff are in a hurry and grabbing supplies or they have to quickly put up after a long day in the OR. First impressions count with surveyors.

As policies are updated and approved by the board during the year, I email them to all staff advising that it might be a small change, but they need to be aware of the change. For new employee orien- tation, the employees are shown where policies and incident reports are kept. This is a frequent question to staff from a surveyor: Do you know where to find your policies and/or an incident report? Throughout the year, I distribute information so that when I am away staff know who services equipment or supplies an item. So, if a room is too hot or a door is not locking properly, they know who to contact.

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