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Check out what JCAHo surveyors focused on during an ambulatory survey

Accreditation Connection, May 17, 2004

Memorial Same Day Surgery Center was one of the first ambulatory centers surveyed under the JCAHO's new survey process, and staff were nervous about how surveyors would score the new standards and how the tracer process would work.

Memorial had already adopted a continuous survey readiness process, but staff spent six months prior to survey actively reviewing the new standards and conducting practice interviews with staff, says Cas Wilson, RN, MS, the nurse manager and postanesthesia care unit manager at Memorial's West campus.

Here's a look at how the on-site visit played out:

During the leadership interview, surveyors met with managers throughout the organization, as well as representatives from the board of directors. Surveyors wanted to know the extent of the directors' involvement in the center's operation, the process managers use to bring problems to the board's attention, and how the board handles quality improvement and risk management plans, says Carl Waskiewicz, the center's executive director. The leadership interview lasted approximately 45 minutes.

Surveyors conducted three patient tracers at both campuses. They selected a gynecology patient, an opthalmology patient, and a gastroenterology patient, says Wilson. Surveyors asked the following questions during the tracers:

Each patient tracer took at least an hour, and surveyors spoke to approximately five people during one tracer, says Wilson. Surveyors also observed a procedure in the operating room (OR). (Note: The center asked the patient and surgeon whether they would object to the surveyor's presence during the procedure before admitting the surveyors, says Waskiewicz.)

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