Volume 2024 | No. 2
SURVEYOR
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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