Credentialing was a big focus in a recent AAAHC survey

Accreditation Connection, December 1, 2003

The last time staff at the Cape Girardeau (MO) Outpatient Surgery Center underwent an AAAHC survey, it happened to fall on a day when no surgeries were scheduled.

This year, however, the surveyor arrived unannounced on a surgery day because the AAAHC's visit was also a deemed-status survey for Medicare reimbursement.

"I told the staff that they do these things correctly every day, and if the surveyor happens to come during a surgery day, they should just do what they do normally," says Suzie Vickery, RN, the center's administrator.

Document peer reviews
Before the survey, Cape Girardeau staff had conducted peer reviews and verbally reported on the outcomes at medical staff meetings, says Vickery. Upon inspection of credential files, the surveyor noted they contained current medical licenses and up-to-date insurance information. However, the surveyor wanted to see written documentation of the peer review process and suggested staff include a formal report in the file with the following information:
  • Physician-specific complications
  • Infection rate among a physician's patients
  • Any hospital transfers required for the physician's patients

Test staff on annual training
The surveyor wanted to know how the center kept track of ongoing training and education and how it kept job descriptions current. Staff have annual job evaluations, and leaders review job descriptions during the evaluation process, Vickery told the surveyor. Leaders at the facility make any necessary changes to the job description during the review and include a copy of the revised description in the personnel folder, she said.

The patient care staff must complete a training program every year as well. The following are the training program details:
  • Training covers a range of topics, such as laser safety, reducing exposure to bloodborne pathogens, and new facility policies.
  • The center has a library with education tapes and books that staff can review on their own time, Vickery says. After reviewing the tapes or books, staff must complete a test.
  • Nurses review the tests and speak with anyone who scores below 80%. The test results are included as part of the annual evaluation, says Vickery.

See a sample educational test in below.

Consultative comments
The surveyor recommended that the center do the following:
  • Develop a formal policy on advanced directives. The center only performs elective procedures with minimal risk, and therefore does not honor advanced directives. The surveyor suggested the center tell patients in writing that it does not honor advanced directives .
  • Don't leave sheets loose in credential or personnel files. Secure all paperwork with fasteners.
  • Restrict privileges to those performed at the center. Do not include everything the physician has been trained in.

About the facility

The Cape Girardeau (MO) Outpatient Surgery Center, is an ophthalmology center that treats approximately 2,100 patients per year. Six surgeons work at the center. One surveyor from the AAAHC visited the center for two days in August.

Sample laser safety training test

1. For what is the term LASER an acronym?

2. What part of the human body is most vulnerable to injury in a laser accident?

3. What is the NHZ?

4. List three nonbeam hazards associated with the use of lasers.

5. Workers may wear the same pair of goggles for protection from any laser wavelength.

6. The HeNe aiming beams are very low wavelengths and can never cause any damage to the eye.

7. The reflected light from a laser beam can cause eye injury to workers in a laser room's Nominal Hazard Zone.

8. What term refers to the smoke some lasers and electrosurgical units give off?

9. Never place liquids on or near any electrical equipment.

10. List three safety items that should be available while using any Class 4 laser.

Source: Cape Girardeau (MO) Outpatient Surgery Center. Reprinted with permission.

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