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Volume 2025 | No. 2
Quality Review Edition THE Accreditation Resource for Data Nerds SURVEYOR
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
03 Corner View
04 From the Program Director
06 Frequent Deficiencies in ASCs
BOARD OF COMMISSIONERS
LEADERSHIP TEAM
Brock Slabach, MPH, FACHE Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CEO, MSMP ANESTHESIA SERVICES, LLC
Leonard S. Holman, Jr., RPh Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES
John Barrett, MBA Officer-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM
Matt Hughes VICE PRESIDENT, COMMUNITY CARE SERVICES Jonathan Kennedy, CPA, MBA VICE PRESIDENT, FINANCE AND CORPORATE SERVICES
Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO
Mark S. Defrancesco, MD, MBA, FACOG Secretary WOMEN’S HEALTH CONNECTI CUT/PHYSICIANS FOR WOMEN’S HEALTH (RETIRED)
Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
Jennifer Burch, PharmD OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS
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Volume 2025 | No. 2
SURVEYOR
CORNER VIEW WITH PRESIDENT & CEO, JOS É DOMINGOS
You made a great decision when choosing ACHC to accredit your surgery center. Whether you are new or have years of experience with us, I am confident that you have already felt first-hand our intense focus on customer service. Real support that builds your team ACHC doesn’t engage in “accreditation theatre” through complex scoring rubrics or punitive surveys that give an illusion of rigor without adding any true value for your organization. Instead, we focus on real support designed to close any gaps between your current state and full standards compliance. We are known as Accreditation Nerds for our genuine belief in— and passion for—the efficacy of accreditation to enhance quality and safety in healthcare organizations. But we know it works best when those organizations understand and embrace continuous performance improvement. The Quality Review edition of Surveyor is an excellent place to start. This publication is a resource, demonstrating how ACHC program teams work to help you develop individual expertise within your ASC, while recognizing that your staff may have varying levels of experience with and current knowledge of accreditation standards. The standards covered are the most frequently cited on recent surveys and the compliance tips are divided into categories to make them useful for individuals across a range of roles and experience. “Accreditation Nerd Newbies” are just that: new to the process of demonstrating compliance with accreditation standards. ACHC uses a Plan- Do-Study-Act framework to organize standards. Even a “simple” standard may include multiple
elements for full compliance. Under Compliance tips for Nerd Newbies, we offer a clear summary of the expectations for each standard. “Accreditation Nerd Apprentices” understand the concepts of meeting and maintaining standards. Compliance tips for Nerd Apprentices focus on using data on hand to continuously assess how well your organization is performing. Finally, “Accreditation Nerd Trailblazers” are those individuals who are passionate about maximizing their organization’s capacity for excellence. They are enthusiasts who eagerly share their knowledge with colleagues to create a path forward. Nerd Trailblazers thrive on the goal of continuous improvement. Compliance tips for Nerd Trailblazers cover best practices designed to level up your organization. These tongue-in-cheek categories are our way of saying that it’s possible to approach accreditation seriously without being humorless. When we say that we want to help you develop your staff into a team of Accreditation Nerds, you immediately understand our goal. Partnership you can rely on Once an ASC is ACHC-accredited, we become your partner, dedicated to meeting your needs. ACHC’s staff of Accreditation Nerds—account advisors, surveyors, clinical educators, quality and regulatory, and other experts— thrive on being helpful. Review the information on the pages that follow confident that we’re ready to dig in to answer questions, provide feedback, offer suggestions, and direct you to any additional resources you need.
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.
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Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
AMBULATORY SURGERY CENTER
This Quality Review edition of Surveyor identifies and analyzes the most challenging standards for ambulatory surgery centers based on data from initial and renewal surveys conducted between June 1, 2024, and May 31, 2025.
Trending the Data Fourteen standards were “not compliant” on more than 25% of the surveys conducted. The three that appeared most often are carryovers from last year. Compliance with standard 03.01.02 Credentialing Files can be simplified by using the required elements as steps. 1. Verify education, licensure, certification, etc. 2. Verify procedural logs, peer reviews, and/or other submissions for evidence of current competence. 3. Confirm reappraisal prior to renewal of privileges. 4. Governing body reviews recommendations from professional staff regarding the applicant. 5. Include a letter granting, denying, or adjusting the scope and duration of privileges. There is no point in reviewing procedural logs, or peer recommendations (step 2), if licensure or certification (step 1) are in doubt. The final step is the letter regarding appointment and privileges that comes from the governing body as confirmation that it has reviewed all relevant material and assumes responsibility for the care this individual will deliver to the ASC’s patients. Deficiency of the infection prevention and control standard 05.00.06 Sanitary Environment will always be a challenge because of the constant change, and wear and tear on the physical environment of the ASC. The best way to improve your level of compliance is to engage all staff
in observation-based environmental rounding. Look at the state of cleanliness and create work orders when dirt, dust, and debris are noted. It’s also important to note that the goal of efficient OR turnover cannot be allowed to undermine infection prevention goals. Establish and follow a process for post-case cleaning of ORs that defines the cleaning agents to be used, dwell-time, waste management, etc. Finally, standard 08.00.03 Form and Content of the Medical Record continues to present challenges for full compliance. The medical record is the complete story of each patient’s health and procedural journey in your ASC. It serves to support continuity of care among providers for each case in the event of an emergency transfer to a higher level of care, and for routine follow-up care. Surveyors noted patient records missing risk assessments, missing anesthesia documentation, and missing dates, times, and authentication. This is a matter of training and building a culture of quality and attention to detail. How can we help? The purpose of this report is to highlight topics of common concern for ASCs. Additional resources are available on the refreshed ACHC website (achc.org/articles), including posts from ACHC experts that support compliance with the standards in this report and others. Also, please visit our education division, ACHCU (achcu.com/ ambulatory-surgery-center-webinars/) for a library of free resources to help your ASC excel.
AMBULATORY SURGERY CENTER ACCREDITATION
FREQUENT DEFICIENCIES FROM ASC SURVEYS
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 01.02.01 02.01.05 02.01.08 03.01.02 04.01.01 04.03.01 05.00.0205.00.0606.00.0308.00.0309.00.03 09.02.02 09.03.01 15.01.02
Physical Environment
Medical Staff
Quality
Infection Control
Patient Rights
Governing Body
Medical Records
Patient Assessment
Administration & HR
Rommie Johnson, MPH Program Director
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CHAPTER 01: GOVERNING BODY 01.02.01 Contract Services Frequency of the citation: 39%
CHAPTER 02: ADMINISTRATION AND HUMAN RESOURCES 02.01.05 Personnel Records Frequency of the citation: 33% Overview of the requirement: The ASC maintains documentation that includes evidence of qualification, current licensure/ certification/registration, and orientation/training/assessments for all employees and providers. Comment on deficiencies: This standard is evaluated through review of documentation. No deficiencies reflected a failure to maintain personnel records, but Surveyors noted specific required items missing from the files. In most cases, content was missing in a subset of files rather than all files reviewed. Examples of ACHC Surveyor findings: ■ Files lacked current BLS/ACLS certificates as required by the organization’s policy. ■ Four of eight files reviewed lacked a completed initial orientation checklist. They were missing signatures and dates of completion. ■ Two files reviewed lacked an annual evaluation for the past two years. ■ Annual evaluations lacked signatures of the reviewer, the individual reviewed, and the date. ■ Files lacked annual competency evaluations in four of 16 files. ■ All files were missing annual training documentation for ethics and corporate compliance, assessment of patient’s risk for self-harm, management of an incapacitated or impaired provider, and communication with outside entities. ■ The employee handbook requires a 90-day evaluation for all employees. However, the human resource policy only requires an annual evaluation. All but one personnel records included a 90-day evaluation. The citation is based on evidence of accepted practice within the organization.
Overview of the requirement: The quality of all contracted services provided by the ASC are the responsibility of its governing body. All contracts must include metrics defining expectations for service delivery. These are incorporated into the ASC’s QAPI Program with results reported to the governing body. Comment on deficiencies: Compliance is evaluated through observation, interviews, and document review. Most deficiencies resulted from services that were not measured for quality and reported to the governing body and others that were not included in the QAPI Program. Examples of ACHC Surveyor findings: ■ Contracted services are not being evaluated by the governing body. The organization had no evidence of meeting minutes for the past year. ■ Although the governing body reviews contracted services annually, they are not incorporated into the ASC’s QAPI Program. ■ Metrics have not been used to assess/approve the continued services of the contracted companies. ■ The following contracts were missing from the list of contracted services and the review process: ٝ Accounting service. ٝ Property management services.
ٝ Biomedical services. ٝ Laboratory services.
Compliance tips for:
The ASC’s governing body holds responsibility for any service provided by or for the organization. For each contracted service, metrics define acceptable performance and these are trended through the QAPI Program, reported to the governing body, and used to make decisions about continuing, altering, or discontinuing the relationship. ■ Create and maintain a list of all contracted services. ■ Audit QAPI committee meeting minutes to ensure inclusion of data from all contractors in reports to the governing body. ■ Create a policy and procedure for inclusion of performance metrics in all contracts for services. ٝ Ensure that the QAPI committee establishes the means and frequency of data collection.
Nerd Newbies (understand the requirement)
Compliance tips for:
The intent of this standard is to ensure an individual file is created and maintained for each employee and contracted provider. Six categories of documentation must be included for a complete file. Surveyors focus on the presence of required documentation from each category when assessing completeness of personnel files.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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Compliance tips for: Nerd Newbies
■ Develop checklists of required items for personnel files. ■ Audit files for inclusion of all required items.
Nerd Apprentices (audit for excellence)
Admission to any health care setting is an opportunity to assess individuals at risk of harm to self or others. The ASC’s goal is to provide a safe environment for all patients, staff, and visitors, to mitigate identifiable risk factors, and to provide appropriate professional referrals. The intent of the standard is to identify at-risk patients, identify environmental safety risks, and identify mitigation strategies. Direct employees, contractors, per diem staff, and others providing clinical care under arrangement are included in the requirement for training. ■ Audit personnel files for inclusion of this element in orientation and training. ■ Document the expectations of your ASC for individual and environmental risk assessments through a policy. ■ Consider adopting the Columbia Suicide Severity Rating Scale (C-SSRS) short form as part of your registration process.
(understand the requirement)
■ Standardize a basic orientation agenda to include all required elements. ■ Standardize a basic annual training agenda to include all required elements. ■ Review relevant policies for items to be included in personnel files (job descriptions, certifications, timing of evaluations, etc.). ٝ Ensure agreement across policies and other materials, e.g., employee handbook.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
02.01.08 Identification of Patients at Risk for Harm Frequency of the citation: 27%
Nerd Trailblazers (prepare the path for others)
Overview of the requirement: Initial employee orientation and annual training must include identification of patients at risk of harm to self or others. Comment on deficiencies: Surveyors review files for initial orientation and annual training that covers individual and environmental risks and mitigation strategies. Deficiencies were noted when there was no documentation of this training. Examples of ACHC Surveyor findings: ■ Based on interview, after review of documentation, the ASC does not currently provide this training. ■ There was no evidence of adoption of a screening process to identify patients at risk of harm to self or others. According to the Clinical Director, the facility was not aware of this requirement. ■ Two of six files lacked evidence of this training at orientation. Six of six files lacked evidence that this training was provided annually.
CHAPTER 03: MEDICAL STAFF 03.01.02 Credentialing Files Frequency of the citation: 57%
Overview of the requirement: A credentialing file is maintained for every applicant for medical staff privileges and all submitted information is retained regardless of whether the applicant is awarded or denied privileges. Comment on deficiencies: Compliance is assessed through document review. Surveyors noted missing required elements. Letters awarding privileges must be signed by the governing body, and must specifically identify the privileges granted and the duration of the appointment (no longer than 36 months). Examples of ACHC Surveyor findings: ■ Documents from seven CRNA applicants were together in one file and lacked evidence that they were granted privileges. ■ 13 of 16 files lacked primary source verification (PSV) of education. ■ One file was granted privileges on 8/7 but PSV of education was not received until 8/12. ■ Files reflected expired malpractice insurance or no evidence of malpractice insurance.
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CHAPTER 04: QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT 04.01.01 QAPI Plan Frequency of the citation: 31% Overview of the requirement: A written plan, approved by leadership, details the annual quality activities of the ASC. The plan identifies priorities that focus 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 quality indicators and how data will be collected, analyzed, and acted upon. Comment on deficiencies: Surveyors interview leaders and staff and review the written plan to evaluate compliance. Deficiencies were cited for plans that did not include all required elements. Failure to include contracted services and to monitor pain management effectiveness were frequently noted. Examples of ACHC Surveyor findings: ■ The QAPI plan did not address the scope of services provided including contractual services. ■ The QAPI plan lacked reference to monitoring the effectiveness of pain management. ■ The QAPI plan did not incorporate patient satisfaction results. ■ Although the facility is tracking the required elements, they are not specifically identified in the written “Quality Assurance Plan.” ■ The QAPI plan lacked detail of the following: ٝ Specific patient safety Indicators. ٝ How data is collected. ٝ How frequently data is collected. ٝ Evidence of data analysis.
■ Three of ten files that had gone through the credentialing/approval process lacked required elements: ٝ One was granted privileges before the requested AMA profile was provided. ٝ One lacked a criminal background check. ٝ One lacked professional reference reports. ٝ Three lacked OIG reports. ٝ Three lacked evidence of current competence, clinical activity, procedural logs or peer review activities. ٝ Three lacked signed attestations to comply with medical staff bylaws. ٝ Three lacked letters from the governing body granting privileges. ■ Letters indicating approval of privileges by the governing body were signed by the nurse manager rather than a representative of that body. ■ Letters granting privileges lacked the duration of the privileges.
Compliance tips for:
Five elements are the minimum requirement for a complete credentialing file: 1. Verification of education, licensure, certification, etc. 2. Procedural logs, peer reviews, and/or other evidence of current competence. 3. Evidence of reappraisal prior to renewal of privileges. 4. Governing body review of recommendations from professional staff regarding each applicant. 5. A letter granting, denying, or adjusting the scope and duration of privileges. ■ Audit files for inclusion of required elements. ■ Cross reference privileges requested with privileges granted/delineation of privileges. ■ Define a step-by-step process for credentialing and privileging. ■ The governing body’s responsibility for the quality of care provided the ASC makes the credentialing and privileging process extremely important. Do not advance incomplete applications for review.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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04.03.01 Risk Management Program Frequency of the citation: 27%
Overview of the requirement: The ASC identifies and assesses potential risks across the organization. It has an established process to identify and review unanticipated events and uses data, analysis, and action to mitigate negative outcomes. Comment on deficiencies: Compliance is assessed through review of the written Risk Management Program. Most deficiencies cited one or more missing required element.
Examples of ACHC Surveyor findings:
■ The program lacked a review of data security risks. ■ The program did not consider medication errors, patient deaths, or data security among the risks assessed. ■ The ASC lacks a risk management plan.
Compliance tips for:
Quality improvement is the primary goal of accreditation. The intent of this standard is to ensure that quality metrics are established and monitored and that corrective action is implemented when performance falls below established thresholds. ■ Think of the annual QAPI plan as a collection of measures specific to each area/department/team in the ASC. ٝ .Audit data you are currently collecting and assign it to services to ensure all areas of the ASC are included. ٝ Audit to ensure a goal is established for each measure. Note: Trending your data over time establishes internal benchmarks and researching national industry norms can provide external benchmarks. Use these to create your goals. ٝ Audit the annual plan to ensure each required element of the standard is addressed. ■ Analyze current performance against goals. Where performance falls short, you have opportunity for improvement. The annual plan should 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. ■ Share improvement projects in progress and when completed with all staff.
Compliance tips for:
Nerd Newbies (understand the requirement)
The standard identifies seven categories of risk that must be assessed at minimum: ■ Unanticipated events. ■ Deaths. ■ Complaints. ■ Grievances. ■ Patient falls. ■ Medication errors. ■ Medical malpractice claims. ■ Data security risks. There must be a process to report unanticipated events and these are reviewed and acted on. ■ Audit the program for inclusion of all required elements. ■ Audit the policy/procedure for reporting unanticipated events. ■ Conduct staff training on the reporting process. ■ Incorporate the findings of individual event review into the risk assessment to ensure mitigation plans are enacted and effective.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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Compliance tips for:
CHAPTER 05: INFECTION PREVENTION AND CONTROL 05.00.02 Infection Prevention and Control Program Development Frequency of the citation: 29% Overview of the requirement: The program to prevent and control the spread of infection in the ASC is based on recognized guidelines. Comment on deficiencies: Surveyors evaluate compliance by reviewing documentation, interviewing staff, and observing infection prevention in action. Deficiencies identified incomplete policies and a failure to implement policies and procedures. Hand hygiene and glove technique was consistently identified in deficiency descriptions. Examples of ACHC Surveyor findings: ■ The organization lacks a policy that addresses compliance with state-level notifiable disease reporting requirements. ■ The facility’s hand hygiene policy requires use of a handwashing agent or alcohol-based hand rub before gloving and after removing gloves. Two staff members were observed exchanging dirty gloves for clean gloves without performing hand hygiene between the exchange. This process was noted to occur two times by each of the two staff members. ■ The ASC lacks an ongoing Infection Control Program. The facility was unable to produce policies and procedure for development and implementation of infection control activities related to personnel. The facility was lacking policies articulating the authority and circumstances under which the ASC screens personnel for infections likely to cause significant infectious disease or other risks to the exposed individual, and for reportable diseases, as required under local, state, or federal public health authority. ■ There was no nail policy for the facility. The RN circulator was wearing ½ inch artificial nails. ■ The facility policy titled “Education,” states that employees will receive infection control training within 30 days of hire and annually that includes: ٝ Hand washing and use of alcohol-based hand sanitizers. ٝ Safe injection practices. ٝ Cleaning and disinfecting the environment. ٝ Infection prevention and follow-up. ٝ Standard precautions. ٝ Bloodborne pathogens. Four staff members did not receive any of this training based on document review.
The ASC is expected to select and adopt nationally-recognized infection control practices, train its staff on infection control, and maintain active surveillance. The standard requires a program that requires at least: a sanitary environment, mitigation of healthcare-associated infections, screening for infection/immunization status, monitoring for compliance, and periodic program evaluation and revision. ■ Audit your infection control policy(ies) against the standard to ensure inclusion of all required elements. ٝ .Identify the source of your guidelines (for example, WHO, CHC, SHEA, AORN, APSF). ■ Audit personnel files to ensure they include initial and periodic training. ■ Review monitoring data so that you can develop and deliver targeted infection prevention training modules to support improvement in infection control practices.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
05.00.06 Sanitary Environment Frequency of the citation: 43%
Overview of the requirement: 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, including water quality, ventilation systems, and storage. Comment on deficiencies: Compliance is evaluated through direct observation, interviews, and reference to policies. Deficiencies noted were all based on Surveyor observation and therefore avoidable by an alert, and action-oriented staff.
Examples of ACHC Surveyor findings:
■ All air vents throughout the facility were dirty. ■ Floors throughout the facility were visibly dirty and unable to be cleaned with a Sani-wipes. The dirt was noted to be “waxed” over. ■ The sink faucet in pre-op room 2 was detached from the sink and the toilet does not flush. ■ Suction tubing was open to air on uncovered shelves in the hallway. ■ In OR2, post room turnover, and just prior to a case starting, dust and waste including used alcohol wipes, needle caps, and papers left from a previous procedure in this room were observed under the table.
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Examples of ACHC Surveyor findings: ■ The ASC’s policy regarding patient rights states, “the ASC shall, prior to the start of the surgical procedure, provide the patient with verbal and written notice of the patient’s rights and responsibilities in a language and manner that ensures the patient understands.” At the time of registration, patients are asked to initial a statement that they have received a copy of their rights. In the 20 charts reviewed, all patients had initialed this statement. Based on observation, they are asked if they want a copy, but no explanation of the rights is given either at the time of registration or at the time of preoperative assessment. ■ Based on observation, patient rights were reviewed orally during the pre-op call, but they were not provided a written copy. ■ Patients were provided with a written document but their rights were not reviewed verbally. ■ The written Notice of Rights provided to the patient contained the patients’ responsibilities; however, the notice lacked information on the patients’ rights. ■ The patient’s guardian required translation services and although this service was provided in- person, the registration forms requiring a signature from the guardian, were not translated in full.
■ Facility policy “Aseptic Technique,” states that after every procedure, the floor is cleaned using a lint- free cloth moistened with an EPA approved disinfectant solution. Observation of a room turnover revealed that the floor is only dry mopped between cases and not damp mopped per facility policy. ■ Rust was noted on IV poles and on tables, carts, and stools with casters.
Compliance tips for:
The ASC is expected to select and adopt nationally-recognized infection control practices, train its staff on infection control, and maintain active surveillance. The standard requires a program that requires at least, a sanitary environment, mitigation of healthcare-associated infections, screening for infection/immunization status, monitoring for compliance, and periodic program evaluation and revision. ■ 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. ■ Establish a schedule for routine cleaning of surfaces, including under sinks, top of warmers, ice machines, and emergency carts. ■ Review room turnover procedures and conduct a “spot the error” training session. ■ Train staff to follow policies as written. ■ Create infection control quality goals related to environmental conditions.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Compliance tips for:
Surgical patients are in an inherently vulnerable position. The intent of this standard is to ensure that they understand that they have rights and a process to exercise these rights. The verbal and written communication do not have to be provided simultaneously, but both must be provided prior to the patient’s movement out of the pre-operative area at the latest. ■ Review your patient rights statement for inclusion of all required elements. ■ Review your patient intake/admission process to ensure both the verbal and written components are covered. ■ Define a process for communicating patient rights in both verbal and written formats. ■ Identify a translation service that can be called upon to assist when English is not the patient’s or their representative’s primary language. ٝ Based on your patient population, documents can be translated in advance for the most frequently needed languages.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
CHAPTER 06: PATIENT RIGHTS 06.00.03 Notice of Rights: Provided to the Patient Frequency of the citation: 31%
Nerd Trailblazers (prepare the path for others)
Overview of the requirement: Prior to the start of a surgical procedure, the patient or their representative is provided with a verbal and written statement of patient rights in a manner that ensures they are understood by the patient or their representative. Comment on deficiencies: Compliance is assessed through observation, interview, and document review. Surveyors noted that either the verbal communication or the written communication was present, but not both. For patients or their representatives who need translation services, both elements (written and oral) are expected to be in a language they can understand.
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Compliance tips for:
CHAPTER 08: MEDICAL RECORDS 08.00.03 Form and Content of the Medical Record Frequency of the citation: 63%
The patient record is the story of the case and the care received. A complete and accurate record is essential for planning the procedure, for handoffs, and for postsurgical review. ■ Establish checklists that identify pre-, intra-, and postoperative documentation for patient medical records. ٝ Assign the documentation items to the appropriate discipline. ■ Audit patient records for inclusion of all elements. ■ Use the results of record audits to identify focused training. Does a department or individual need coaching on requirements? ■ Review policies and procedures regularly. An updated workflow can put staff in conflict with the ASC’s policies if they are not revised to reflect changes.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Overview of the requirement: Each patient of the ASC has a complete, accurate, and legible medical record that includes at least eight data points described by the standard. Comment on deficiencies: Surveyors review open and closed medical records. Because of the large number of required elements, this standard is a frequent deficiency year after year. This year, a significant number of deficiencies tied to anesthesia documentation.
Nerd Trailblazers (prepare the path for others)
Examples of ACHC Surveyor findings: ■ Records for anesthesia lacked:
CHAPTER 09: PATIENT ASSESSMENT 09.00.03 Presurgical Risk Assessment Frequency of the citation: 29%
ٝ Evidence of a recovery evaluation by an anesthesia provider (15 of 16 records). ٝ Evidence that the anesthesia machine was checked prior to start of the procedure (16 of 16). ٝ Documentation of the anesthesia machine number associated with the procedure (16 of 16). ■ The intra-operative anesthesia record lacked times that vital signs were obtained and medication administered. ■ Although all records reviewed included a pre-anesthesia assessment, the assessments were not dated or timed, making it unclear when they were performed. ■ Three of ten medical records lacked a discharge order. ٝ Four of ten were missing documentation by a nurse that the patient’s post-op discharge criteria were met. ■ Records lacked a pre-surgical risk assessment. ■ Half the records reviewed included an H&P performed more than 30 days prior to the surgery. ■ Three records noted, “Pt. evaluated by a responsible physician and is ready for discharge.” All three were transferred to the ER. ■ According to facility policy, “The medical record should include: 1. Legible handwriting 2. No empty lines or spaces 3. A discharge diagnosis.” An interview with the PACU RN revealed the post-op diagnosis documentation was removed when they transitioned to using EMR.
Overview of the requirement: Immediately prior to surgery, a physician who will be performing the surgery examines the patient to evaluate the risk of proceeding with the procedure. Comment on deficiencies: Compliance is evaluated through review of patient records. Almost all deficiencies noted missing presurgical risk assessments.
Examples of ACHC Surveyor findings:
■ Records reviewed lacked a presurgical risk assessment. ■ Four of 20 records included a presurgical assessment that lacked a check mark in the box indicating whether the H&P was reviewed and unchanged. ٝ One of 20 contained a pre-surgical risk assessment that was blank. ٝ One of 20 contained a pre-surgical risk assessment that lacked a date and time of completion.
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Compliance tips for:
Compliance tips for:
Recovery from anesthesia must be evaluated and documented by a physician or anesthetist. A handoff report is provided at the beginning of the post- anesthesia process by the anesthesia provider to the receiving nurse and documented in the post-anesthesia care record. The patient’s condition is monitored and an evaluation of the recovery from anesthesia is completed and documented prior to discharge. ■ Audit patient records to confirm that all required post-anesthesia documentation is present, timed, and signed. ٝ Confirm that timing makes sense based on when the patient left the OR. ■ Create post-anesthesia care checklists to ensure inclusion of all required elements. ٝ For EMRs, work with your IT team to prevent advancing to discharge documentation if the post-anesthesia evaluation is incomplete.
Appropriate case selection is essential for surgical services provided on an outpatient basis. Because a patient’s health status can change from the time of scheduling to the day of the procedure, a risk assessment immediately prior to surgery ensures that the case remains appropriate for the ASC setting. This presurgical assessment is distinct from the pre-anesthesia assessment. It addresses the patient’s current condition, any comorbidities, and identifies any allergies or sensitivities to drugs and biologicals. The result of the assessment is documented, even if there are no concerns identified. ■ Audit records for inclusion of the presurgical risk assessment.
Nerd Newbies (understand the requirement)
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
■ Develop a checklist that incorporates all required elements. For an EMR, require completion of the presurgical risk assessment to advance through the record.
Nerd Trailblazers (prepare the path for others)
09.03.01 Discharge Order Frequency of the citation: 33%
09.02.02 Post-Anesthesia Evaluation and Care Frequency of the citation: 33%
Overview of the requirement: No patient may be discharged from the ASC without a discharge order signed by the physician who performed the surgery. Comment on deficiencies: Compliance is assessed through review of closed patient records. Deficiencies were cited for missing discharge orders and orders that were incomplete. Often, an untimed or unsigned entry was a factor.
Overview of the requirement: Each patient’s recovery from anesthesia is evaluated by a physician or anesthetist prior to discharge from the ASC. Comment on deficiencies: Compliance is evaluated through document review. Deficiencies resulted from missing elements. Surveyor comments centered on issues related to documentation of times.
Examples of ACHC Surveyor findings:
Examples of ACHC Surveyor findings: ■ Records reviewed lacked evidence of a post-anesthesia evaluation after propofol. ■ Records of post-anesthesia recovery did not document a temperature check.
■ Six of 20 records reviewed lacked a discharge order. ■ The pre-printed order sheet was signed, dated, and timed by the physician but the checkboxes to indicate an order were all empty. ■ The ASC lacks a policy for discharge orders. The clinical director could explain the process used but could not produce a written policy.
■ Records lacked the time that the evaluation was performed. ■ There was no documented handoff report to the PACU nurse.
■ Nine of 20 records included a post-anesthesia evaluation that was signed and timed by the anesthesia provider after the patient was discharged home, making it unclear when the assessment occurred. ■ Two of twenty records contained documentation by the anesthesia provider of a post anesthesia evaluation that occurred one minute after the patient’s documented time leaving the OR.
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■ Daily air exchanges did not meet the ASHRAE standard of at least 20 per hour. They were noted for OR1 at 17.5 positive exchanges per hour and for OR2 at 17.6.
Compliance tips for:
ASCs must ensure that each individual patient has recovered adequately to be discharged home or transferred for additional care. The decision is the responsibility of the physician who performed the surgery.
Nerd Newbies (understand the requirement)
Compliance tips for:
Temperature, humidity and air exchange rates support infection prevention in surgical environments. Daily readings when ORs are intended for use provides an opportunity for proactive mitigation anytime these readings are out of appropriate range. ■ Log temperature, humidity, and air exchange rates for each OR on each day of use and prior to the beginning of each case. ■ Take immediate action to correct an environment that does not meet the required conditions. ٝ Reversed air pressure relationships can often be Immediately corrected but not if they are unknown. ■ If you use contracted services for HVAC, educate your vendors on the requirements of your surgical facility so that they can take quick action to avoid case cancellations.
■ Audit patient records for inclusion of discharge orders.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
ٝ Check for date, time, and signature of the physician who provided the surgical services. ■ It is acceptable for an operating physician to write an order for “discharge when stable” but the criteria applied must be documented along with a time.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
CHAPTER 15: PHYSICAL ENVIRONMENT 15.01.02 Temperature, humidity and air-flow requirements Frequency of the citation: 35% 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 and ASCs must maintain logs that demonstrate these are maintained. Comment on deficiencies: Compliance is evaluated through document review and direct observation. Most deficiencies noted a failure to document airflow/exchange rate for each day that the OR is used. Additional deficiencies noted that no corrective action was taken when readings were out of the required range (temperature or air exchange). Examples of ACHC Surveyor findings: ■ The ASC monitored and recorded the daily temperature and humidity of the ORs and sterile areas, but it did not monitor positive and negative room air pressures. ■ Documentation of air pressure in cardiac catheterization, decontamination, clean supply, and sterile supply, was logged monthly and must be logged daily when ORs are in use. ■ On two dates, the temperature was recorded as our of range (high) for the first case. The facility documented the temperature at the start of each case done on these days, and it remained above the acceptable range through 15 procedures performed. According to the policy, “Humidity and Temperature Control in the OR,” if the temperature goes outside the required range, the nursing supervisor will be notified, and procedures will be stopped until the issue is resolved.
Nerd Trailblazers (prepare the path for others)
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NOTES
NOTES
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THE Accreditation Commission for Health Care
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