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.


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