search.noResults

search.searching

dataCollection.invalidEmail
note.createNoteMessage

search.noResults

search.searching

orderForm.title

orderForm.productCode
orderForm.description
orderForm.quantity
orderForm.itemPrice
orderForm.price
orderForm.totalPrice
orderForm.deliveryDetails.billingAddress
orderForm.deliveryDetails.deliveryAddress
orderForm.noItems
FEATURE Three years ago when we were up


for a survey, we hired a consultant to conduct a mock survey. We found this very helpful as they are often surveyors themselves. We are planning on doing this again this fall. I am fortunate that I also have many resources between our hospital partner and the practice that I can consult when I am unsure of how to proceed on an issue.


What are the most common areas where ASCs get dinged during surveys? PAGE: It seems to me, at least here, that it tends to be more paperwork issues rather than practice issues that we falter on. For instance, I did not have a pol- icy for an impaired provider, so we were dinged. During the next survey, we were dinged because we did not have one for an incapacitated provider. The policy for both cases would be the same. Surveyors also scrutinize H&Ps, employee records/training, grievances,


transfers and delineation of privileges (DOP). It is easy to misplace something because there is so much paperwork involved. We have an electronic medi- cal record (EMR), but for outside phy- sicians, paperwork is faxed in and later shredded once scanned into the record. Wouldn’t you know the last time we were missing an H&P from one of our outside providers? Of course, we would not do a case without one. Nevertheless, it was missing so we were dinged.


Any specific recommendations for interviews during a survey? PAGE: I have a very capable direc- tor of the OR/PACU who also works on quality improvement (QI) and is the infection control nurse. I find it extremely helpful to have her with me during the interviews as you do not always remember every detail your- self and she is as familiar with the pol- icies as I am. The surveyors are usu- ally very good about explaining the


rationale of why they are not satisfied with some practice or policy and give recommendations for how to make a correction. Thus, having someone with me helps me recall what exactly was said when it is time to rewrite a policy and/or work on a plan of cor- rection. I have been through several surveys, but still the process can be somewhat nerve racking.


Any specific recommendations for document/record keeping for a survey? PAGE: It does seem as if surveyors really focus on employee charts—mine could certainly get more attention than they do from me and sometimes are not organized the way surveyors like, etc. They also like in-depth board of management (BoM) minutes so they know what is really going on with an organization, i.e., is the BOM review- ing research policies, etc.


What are your recommendations for helping smaller ASCs stay on top of regulatory compliance? PAGE: I believe you have to read a lot to stay informed about what is chang- ing in health care. I realize employees can see you reading and think you are not doing anything while they are busy, but trying to keep the center from incur- ring fines and practicing safely is vital. ASCA Connect [ASCA’s members-only online community for ASC profession- als] is very helpful for monitoring con- cerns and issues in ASCs. It has to be very difficult when the directors are also staffing a room and then they have the regulatory burden on top of that.


Anything you’d like to add that I didn’t ask? PAGE: I am part of a group of surgery centers that our hospital partner put together, so once a month we get together via Skype. This is helpful for staying current on issues. We review recent sur- veys—what the surveyors were looking for—and discuss ASC standards.


22 ASC FOCUS OCTOBER 2018 |www.ascfocus.org


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48