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Manage by Checklist Succeed in your next survey using this simple tool BY ROBERT KURTZ


W


ith so many state and federal reg- ulations and accreditation stan-


dards to keep track of, ASCs would be wise to use any tools at their disposal that help meet them, says Alana Booth, RN, CASC, administrator for PCET Surgery Center in Knoxville, Tennessee, and sur- veyor for the Accreditation Association for Ambulatory Health Care. “It can be overwhelming for an administrator, especially one who is new to surgery centers or not sea- soned, to run an ASC,” she says. “Use of checklists can be helpful in ensuring nothing is overlooked or missed.” One such checklist that ASC professionals can use to prepare for surveys by the Centers for Medicare & Medicaid Services, the state and/or accrediting organizations would be a list of frequently missed survey items, says Amy Mowles, president and chief executive officer of Edgewater, Maryland-based Mowles Medical Practice Management, an


ASC


regulatory and development company. “When surveyors visit an ASC, there are numerous documents they will request and review as part of the survey process,” Mowles says. “It can be easy for ASCs to lack one or more documents, but this is not acceptable from a survey or patient care perspec- tive. A checklist of frequently missed survey items will reduce the likelihood of this occurring.”


There are a number of ways to


assemble a checklist of frequently missed survey items, Booth notes. “A good first step would be to read through all of the current standards and require- ments. Check to see whether you have the documentation necessary to meet them. If you are missing an item, note what it is and begin to build a list.”


presentations, and during network- ing—as particularly challenging or commonly missed.” To make


the list of


frequently


missed items more manageable, orga- nize it by topic area, Mowles suggests. “For example, you could categorize items under governance, contracted services, staffing and logs.” Booth adds, “If you have all of these items in one place, sectioned off under those critical areas, it will help with organization. It may take some time to create an initial, organized list, but once it is done, meeting stan- dards and maintaining compliance will be easier.”


Use of checklists can be helpful in ensuring nothing is overlooked or missed.”


— Alana Booth, RN, CASC PCET Surgery Center


Mowles says performing a mock


survey or simply walking around the ASC and reviewing documentation used by staff is another way to identify items that might be missing or com- pleted improperly. The frequently missed survey items list can also include items that your ASC might not actually be missing, she says. “The checklist can serve as a way for ASCs to double check items that may be more challenging. These could be documents that the ASC’s staff struggles to complete, and also items identified by accreditors, sur- veyors and other ASCs—in stories and


30 ASC FOCUS NOVEMBER/DECEMBER 2015


Once the checklist is complete, ASCs can use it to identify any miss- ing documents in need of creation or gathering, Mowles says. “ASCs should then review the checklist periodically to make sure nothing is falling through the cracks, and review it more fre- quently leading up to a survey, if the date is known.”


ASCs that use a frequently missed


items checklist should update it regu- larly, she advises. “Revise it yearly to reflect changes in requirements and standards, when you hear about ASCs struggling in new areas and definitely after a survey if you were found to be missing or having incomplete docu- mentation. ASCs that take the time to put together a checklist of frequently missed items and then use it to deter- mine whether all documentation is completed and available for surveyors are more likely to achieve a successful survey and deliver high-quality, com- pliant care.”


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