SURVEYOR Volume 2024 | No. 2 Quality Review Edition
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
BOARD OF COMMISSIONERS Brock Slabach, MPH, FACHE I Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CHIEF EXECUTIVE OFFICER, MSMP ANESTHESIA SERVICES, LLC Mark S. Defrancesco, MD, MBA, FACOG I Secretary PAST PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Leonard S. Holman, Jr., RPh I Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT Roy G. Chew, PhD I Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK John Barrett, MBA I Board Member-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Jennifer Burch, PharmD PHARMACIST/OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
02 CORNER VIEW
04 FROM THE PROGRAM DIRECTOR
05 FREQUENT DEFICIENCIES IN AMBULATORY SURGERY CENTERS
LEADERSHIP TEAM
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES Matt Hughes VICE PRESIDENT, CORPORATE STRATEGY Barbara Sylvester, RN, BBA, MSOLQ DIRECTOR, REGULATORY AFFAIRS AND QUALITY
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Welcome to the 2024 Surveyor Quality Review. Each year, program-focused editions of this CORNER VIEW publication analyze compliance with ACHC standards over 12 months of surveys. This year’s data span initial and renewal surveys conducted between June 1, 2023, and May 31, 2024. ACHC-accredited organizations use the data to benchmark their performance by comparing these frequently-cited standards against their own survey report. There is value for non-accredited organizations, too. Because ACHC standards are closely aligned with CMS requirements, the information is relevant regardless of how your organization achieves its Medicare certification. For programs outside the Medicare regulations, the value remains. ACHC standards represent an important risk management/quality improvement framework. Reviewing the kinds of issues that arise in your peer organizations is an opportunity to act preemptively to manage your own risks. This is a critical business function in all healthcare settings. We know that some standards consistently present more compliance challenges than others. Frankly, if we offered only a list of frequent deficiencies, this publication wouldn’t vary much from year to year. Instead, Surveyor Quality Review gives insight into trends by quoting findings and offering practical tips to avoid citations. Some standards appear almost annually because of a large number of required elements. Perhaps a policy needs clarification, or staff members were not fully trained on a revision that impacts their work. Perhaps new or contract employees were not adequately oriented to a requirement for documentation, or employees made a change in their workspace that compromises fire safety. For a complex standard, any of these examples represents a potential deficiency and a risk to the organization, its staff, or its patients.
By sharing the observations of ACHC Surveyors, we offer an expert’s perspective on the most current issues impacting organizations. Trends by Program Internally, we use these data to guide the development of educational resources. Organizations seeking to renew their ACHC accreditation in 2024 were also surveyed in 2021. This year, our leaders are including comparative comments as they introduce their program findings. When we experience a large uptick in the number of initial surveys, as we have for several programs in this period, those difficult standards are likely to be prominent as new organizations confront them for the first time. However, we hope to see at least incremental improvement in standards that appeared as frequent deficiencies for this cohort of organizations three years ago. If we don’t see triennial improvements for some of the most frequently cited standards, it means we need to give more educational focus to these in the resources (webinars, workshops, tools) we offer. It is never ACHC’s intention to leave clients wondering about what is expected. To the contrary, our goal is to provide a range of resources that engage and enrich the experience of continuous quality improvement in the healthcare markets we serve. In this year’s first issue of Surveyor , I wrote about team collaboration and handoffs. Remember that ACHC serves as an extension of your team, ready to confer and coach. With Surveyor Quality Review , we are passing an evidence-based guidance tool to you. I hope you grasp it firmly and run with it!
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
José Domingos President & CEO
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FROM THE PROGRAM DIRECTOR
The 2020 merger of ACHC and HFAP included significant efforts to provide a smooth transition for existing HFAP customers and a warm welcome to new and transitioning organizations. This year’s represents a milestone for the Surveyor ASC Quality Review Edition . The data now span a period that allows comparison with survey results reported in 2021. This comparison is relevant as a progress check for the surgery centers that were surveyed as HFAP became part of ACHC. In 2022, standards for deemed and non-deemed surveys were separated, chapters reordered, and slightly divergent requirements established. Throughout my comments below, when comparing 2021 and 2024 data, revised standard numbers are noted. Trending the Data Surveyors identified thirteen standards as “not compliant” on more than 20% of surveys. Two of the three most frequent deficiencies from 2021 related to credentialing files and maintenance of the physical environment from an infection prevention perspective. Both of these appeared again this year and both saw a notable increase in citations compared to three years ago. For example, standard 03.01.02 Credentialing Files (06.00.03 in 2021) was the most frequently cited standard in 2021 with a 38% deficiency rate. This year, it was again the most frequently cited, but at a rate of 64%. Closely related standards for verifying credentials ( 03.01.01 ) and completing a reappraisal process at least every 36 months ( 03.01.05 ) were also noted on more than 20% of surveys conducted. As a set, these standards are intended to ensure that patient care is delivered by well-qualified providers with current medical credentials and currently demonstrated competency. An ASC that allows providers to work without a criminal background check, with a lapsed license, or without the required experience performing a specific procedure puts itself at significant disadvantage in the face of an adverse event or legal action.
Deficiency of the infection prevention and control standard requiring a Sanitary Environment (12.00.02 in 2021; 05.00.06 this year) increased in frequency from 25% of surveys to 38%. The surveyor comments three years ago were focused on dust, rust, and the integrity of surfaces (floors, walls, and doors). Some of these were noted again this year. Other findings called out sterile items that were opened in advance of their use, especially oxygen masks and tubing. Corrugated cardboard continued to be an issue as well. When corrugated boxes cannot be eliminated, a documented risk assessment can be used to mitigate their presence. However, co-mingling corrugated cardboard with clean linen or patient care supplies will always be cited. In 2024, standard 08.00.03 Form and Content of the Medical Record continues a trend from the past two years, presenting a challenge to half of the ASCs surveyed. Prewritten, pre-signed medication orders and missing or inaccurate discharge orders were noted at several ASCs. Each patient record must reflect complete and accurate documentation. This is the story of the individual patient’s care. It is a critical communication channel among providers within the ASC, in the event of an emergency transfer to a higher
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 02.01.03 02.01.05 02.01.06 02.01.07 02.01.08 03.01.01 03.01.02 03.01.05 04.01.01 05.00.06 08.00.03 12.00.03 15.01.02 FREQUENT DEFICIENCIES IN AMBULATORY SURGERY CENTERS
level of care, and for routine follow-up care. Help ACHC Help Your Organization
The purpose of this report is to highlight topics of common concern for ASCs. I hope that you find this information useful, and I welcome your feedback on ways that the ASC team can continue to add value to your accreditation experience.
Rommie Johnson, MPH Program Director
Administration
Medical Staff
Quality Infection Control
Medical Records
Emergency Management
Pharmaceutical Services
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CHAPTER 02: ADMINISTRATION 02.01.03 Position Descriptions Overview of the requirement:
There are written position descriptions for all employee roles not covered by the credentialing and privileging process, including leadership and contract staff. Compliance is evaluated through interviews and review of personnel files. This standard was also cited at a similar frequency in last year’s report but was not an issue in 2021. Citations occurred when an individual’s description of their responsibilities did not correspond to the position description in their personnel file. Often, important tasks get “added on” to an individual’s role on an ad hoc basis and appropriate documentation is overlooked.
Comment on deficiencies:
Frequency of citation:
28%
Examples of surveyor findings:
n Job descriptions were not found for the roles of quality, laser safety officer, and risk management. n Based on the interview with the director of nursing, the DON has been given responsibility for infection control and quality management. His personnel file contains job descriptions for the roles of director and IC, the file lacks a job description for the quality management role. n During discussion with the radiology tech about her duties, she confirmed that she fills in for sterile processing tasks when needed. She verbalized the correct procedures for those tasks, but they are not referenced in her personnel file. n Tie position descriptions to the role, not the individual. Establish a written description for each role/function. If a credentialed and privileged member of the medical staff also serves as administrator, risk manager, quality manager, etc., a description of each additional role for which this individual is responsible is present in the HR files.
Tips for complianc e:
Inventory all roles in your ASC and create job description sheets that can be added to individual personnel files as responsibilities are assigned.
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n Evaluate competencies as part of the initial orientation and training process and note annual competency assessment on a master calendar. n Conduct periodic audits of personnel files for accuracy and completion.
02.01.05 Personnel Records 02.01.06 Orientation Plan 02.01.07 Staff Training 02.01.08 Identification of Patients at Risk for Harm
To keep adverse events rare, training is critical. Staff must know how to manage situations with a potential impact on patient care or safety.
Overview of the requirement:
These closely-related standards require that the ASC maintain individual personnel records for each member of the ASC staff (including contracted staff) that include evidence of qualification, current licensure/certification/ registration, initial orientation, ongoing training, and competency assessment. Compliance is evaluated through review of personnel files. Standard 02.01.05 identifies six types of items that constitute a complete file. No deficiencies cited a failure to maintain personnel records, but many noted missing elements within a category, e.g., orientation (02.01.06) or annual training (02.01.07). The requirement to assess patients for risk of harm to self or others (02.01.08) was introduced in 2022. It is grouped with these standards because many ASCs were did not include this assessment in staff orientation and/or training.
Consider adopting the Columbia Suicide Severity Rating Scale (C-SSRS) short form as part of your registration process.
Comment on deficiencies:
CHAPTER 03: MEDICAL STAFF
03.01.01 Applications for Medical Staff Privileges 03.01.02 Credentialing Files 03.01.05 Reappraisal and Renewal of Privileges
Frequency of citation:
02.01.05: 23%; 02.01.06: 25%; 02.01.07: 26%; 02.01.08: 38%
Examples of surveyor findings:
n Two of 17 files lacked evidence of a current nursing license. n Among files reviewed, individual files lacked evidence of orientation to or annual training on: » Patients’ rights. » Managing adverse events. » Ethics and corporate compliance. » Management of an incapacitated or impaired provider. » Handling hazardous waste. n Based on Interview and document review, the ASC has not provided training on the identification of patients at risk for har m. n All files reviewed lacked evidence of an annual employee evaluation. n One employee file for a radiology technologist included a competency assessment signed by an individual not trained in radiology. n Standardize an orientation agenda that includes all required elements. Do the same for items that require an annual training update. n Orient and train contract and temporary staff. n Note license/registration/certification expiration dates on a master calendar with renewal reminders well ahead of those dates.
Overview of the requirement:
Privileges are granted by the governing body based on complete applications with documentation to support assertions of credentials related to education, training, competence, and mental/moral fitness. Renewal of privileges follows a similar, defined process at least every 36 months, or whenever additional privi - leges are requested. Compliance is assessed through review of credentialing files. Deficiencies were noted for missing applications, missing follow-up actions by the ASC, or a failure to complete the reappraisal process. The large number of required elements in these standards creates many opportunities for error, but the credentialing and privileging process is critical to the ASC’s ability to ensure that patient care is delivered by qualified providers whose performance meets established quality indicators.
Comment on deficiencies:
Frequency of citation:
03.01.01: 23%; 03.01.02: 64%; 03.01.05: 23%
Examples of surveyor findings:
n Files for contracted anesthesia providers did not contain an application for privileges. n Over 70 % of provider files did not include an application for privileges. n Files did not include evidence of a criminal background check. n Letters granting privileges were signed by the credentialing staff rather than a member of the governing body acting in that capacity. n Credentialing files were missing procedural logs demonstrating skills and experience for the procedures requested and approved.
Tips for compliance:
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CHAPTER 04: QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT 04.01.01 QAPI Plan Overview of the requirement:
n Letters granting privileges were dated earlier than the NPDB, OIG, and AMA profiles, indicating that these verifications were not used In the process of granting privileges. n One reappointment file included an expired medical license. n Two credentialing files approved privileges that were not performed at the ASC, indicating a reliance on credentialing at another organization. n Files indicated that privileges had expired prior to completion of the reappointment process. n Reappraisal documentation lacked documentation of peer review including post- surgical transfers, surgical site infections, and other complications. n Credentialing files indicated reappointment for several providers for whom there was no evidence of meeting the minimum number of procedures for reappointment, per medical staff bylaws. n Review relevant ASC policies annually to ensure that all required items are listed and use this to develop a checklist of all items required for privileges to be granted. Identify contacts for credential verification (CVO), if used, and for background checks. n Do not advance requests to the governing body until all required elements are available for review. n Track expiration dates for medical staff licenses, privileges, etc., through a calendar event and issue renewal reminders. ASCs may not rely on another organization’s credentialing and privileging. If a physician provides surgical services at a hospital and at an ASC, the ASC must independently verify credentials and grant privileges based on its own scope of service. When a parent organization operates multiple ASCs, one credentialing process is acceptable, if the approved privileges are specific to all locations for they are approved.
A program to assess quality and complete activities designed to improve performance is developed and implemented. The overall program focuses on high-risk, high-volume, and problem-prone areas with the goal of achieving improvements to patient safety and quality of care. A plan defines what quality measures will be used and how data will be collected, analyzed, and acted upon. Compliance is assessed through staff interviews and document review. Most citations resulted from lack of adequate specificity in defining the plan or failure to identify performance indicators for all areas of the ASC, including contracted services.
Comment on deficiencies:
Frequency of citation:
23%
Tips for compliance:
Examples of surveyor findings:
n The organization’s QAPI Plan lists high-volume, high-risk procedures that are not performed at the ASC. n The plan lacked quality indicators for contracted services. n The plan did not define the collection of indicator data (what data, method and frequency of collection), its analysis, or the process for implementing corrective action and evaluating its effectiveness. n Your QAPI program is a collection of individual plans addressing each area/ department/team in the ASC. n Rather than trying to begin by defining quality measures for each area, start by auditing the data you are currently collecting. Categorize it by service and make sure all areas of the ASC are included. n Identify goals for each measure. Trending your data over time establishes internal benchmarks and researching national industry norms can provide external benchmarks. Use these to create your goals. n Where current performance falls short of the goal, you have an opportunity for improvement. Prioritize action in those areas where risk, volume, incidence, prevalence, or severity are high. Select quality improvement activities with potential for positive impact on patient safety or quality of care. n Implement change incrementally. Simultaneous changes will make it difficult to identify the driver of improvement. n Remeasure after corrective action to assess effectiveness.
Tips for compliance:
Quality improvement is the primary goal of accreditation.
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CHAPTER 08: MEDICAL RECORDS 08.00.03 Form and Content of the Medical Record Overview of the requirement:
CHAPTER 05: INFECTION PREVENTION AND CONTROL 05.00.06 Sanitary Environment Overview of the requirement:
Each patient of the ASC has a complete, accurate, and legible medical record that includes defined information. Compliance is assessed through record review. The standard includes a list of eight required elements and citations are noted when any element is missing. A significant number of deficiencies tied to aspects of the discharge process.
All areas and equipment in the ASC must be maintained to avoid sources and transmission of infection. Policies define expectations for specific aspects of environmental cleanliness, and these are based on nationally recognized infection control guidelines. Compliance is evaluated through direct observation and reference to policies. Deficiencies noted were all directly observable and therefore avoidable by an alert, and action-oriented staff.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
51%
Examples of surveyor findings:
n The organization completes all medical record forms on the day of service, at the time of registration. Forms are pre-signed by the provider and indicate no date or time raising concerns about the authentication process. n Five of ten records reviewed included an H&P that was performed more than 30 days prior to the procedure. n Six of 20 records reviewed did not include a pre-surgical assessment. n Records were lacking vital signs within the anesthesia risk evaluation. n A patient with suspected pneumothorax was ordered and sent for a chest x-ray, but no resulting report was included in the record. n Records omitted documentation of a surgical time-out. n Records lacked an OR-to-PACU handoff report. n Closed patient records did not include a discharge order. n Each patient is given a prescription for Zofran PRN on discharge. There is no order for Zofran on the charts. n Records of two patient transferred via ambulance to a hospital emergency department lacked documentation required by the ASC’s policy, “Recognition of Patient Deterioration.” n Discharge instructions state “do not drive any vehicle for the remainder of today,” but patients were allowed to drive themselves home.
Frequency of citation:
38%
Examples of surveyor findings:
n Opened sterile supplies were observed in unused spaces: oxygen masks with tubing packages in three PACU bays; suction tips and NG tube in the anesthesia cart of OR2. n Rust was observed on casters of surgical tables and mayo stands in OR1, 3, 4. n Of 22 pre- and post-op bays, 21 had open suction tubing attached to the suction equipment. The last had tubing still sealed in the wrapper. n One used surgical bunny suit and shoe covers were draped over clean supplies (medications) in the pharmacy receiving and storage room. n Corrosion was visible on scrub sink faucets at the point of water flow. n Dust, dirt, and debris were observed under the sink in pre-op, on top of the warmer, on top of the ice machine, on top of the emergency cart, on the fire alarm system panel obscuring the screen readout. n The integrity of OR floors, walls, and doors was not maintained. n Corrugated boxes are stored with clean patient care supplies and clean linen. n The organization does not have a spill kit as required by OSHA. n After a patient left the pre-op room to go to the OR, the blood pressure cuff, pulse oximeter, EKG leads, cords, and chair were not sanitized before the next patient entered this room. According to facility policy “Patient turn- overs,” all areas that come in contact with patients are to be cleaned with an approved germicidal agent after use, between cases, including but not limited to chairs, B/P cuff, oxygen monitors, EKG leads, and cords. n Train staff to follow your policies as written. n Create infection control quality goals related to environmental conditions. n Conduct regular infection control surveillance rounds for equipment and environmental issues like rust, surface flaws (divots, chips, separations), dust accumulation, etc., to promote a culture of cleanliness. n Establish a schedule for routine cleaning of surfaces, including under sinks, top of warmers, ice machines, and emergency carts.
Medical records support continuity of care. Do not allow goals for efficiency to supersede the importance of complete and accurate records.
Tips for compliance:
Tips for compliance:
n Establish baseline checklists that identify pre-, intra-, and postoperative docu- mentation for patient medical records. n Train staff on policies related to medical records. n Complete and accurate records are critical for continuity of care when an unanticipated patient transfer occurs. Ensure that responsibilities are assigned to team roles within the appropriate scope of practice. n Conduct rando m file audits quarterly or as defined by your policy.
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CHAPTER 12: PHARMACEUTICAL SERVICES 12.00.03 Drug and Biological Orders Overview of the requirement:
Drug preparation and administration meets accepted standards of practice and established policies. Drugs and biologicals are ordered by and administered under the supervision of qualified professionals. Compliance is evaluated through direct observation and document review. Most deficiencies noted pain medications prescribed without a pain scale to guide ordering/administration of these medications or practice that was in direct con- flict with written policy.
Comment on deficiencies:
Frequency of citation:
23%
Examples of surveyor findings:
n Three prescription pads were found in an unsecured cabinet with prefilled sheets for Zofran including the physician’s signature. These were given to every patient by the pre-op nurse for home use. there was no corresponding order noted in the medical record. n The organization uses two sets of standing orders that require nurses to make judgments about the severity of patients’ pain levels. Neither the order sets nor nursing policies delineate thresholds for pain. n Medical records contained orders for fentanyl, dilaudid, and oxycodone for “PRN pain” with no defined thresholds to guide prescribing. n Pre-op orders lacked required authentication. n One organization policy provides guidelines for range dosing. The policy, “Physician Order’s” states “Range orders are not allowed at the surgery center.” n A sample drug was present and through interview it was confirmed that it was being given to select patients and documented in the medical record. The “Sample Drug” policy states “No sample drugs will be utilized.” n Ensure that policies are not in conflict with each other. n Do not write medication orders prior to their intended use. n Train staff regarding requirements for authentication of orders.. n Establish pain scales to ensure consistent and appropriate dosing.
CHAPTER 15: PHYSICAL ENVIRONMENT 15.01.02 Temperature, Humidity and Air-flow Requirements Overview of the requirement:
Ranges for OR temperature, humidity, and air exchange rates comply with American Society for Heating, Refrigerating, and Air Conditioning (ASHRAE) requirements. Compliance is evaluated through document review and direct observation. Deficiencies were cited for failure to track temperature, humidity, and especially, airflow or for these to be outside of policy range with no corrective action taken to establish a more controllable environment.
Comment on deficiencies:
Tips for compliance:
Frequency of citation:
28%
Examples of surveyor findings:
n Air pressure relationships are not being monitored in the ORs. n Daily temperature, humidity, and airflow logs showed inconsistent documentation of airflow. n During surgery, the humidity in OR2 was observed to be 72%.
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NOTES
n The ASC does not have direct control over the temperature and humidity and the building’s facilities department must be called for adjustments “frequently.” During the survey, a call was placed at 10:20 a.m. to facilities when the humidity was noted as 70%. A second call was placed at 11:55 a.m., and at 1:30 p.m., it was discovered that nine cases had been performed that day with the humidity outside the 30-60% range required by ASC policy. The Administrator and Medical Director declared an “HVAC emergency” and canceled further cases pending a sustainable repair. n Take action as soon as a reading indicates that the environment does not meet required conditions. n Reversed air pressure relationships can often be Immediately corrected but not if they are unknown. Monitor and log air pressure.
Tips for compliance:
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ACHC Redefining the Culture of Accreditation
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