Safety

Credentialing, documentation key in AAAHC survey

Ambulatory Safety Monitor, January 14, 2004

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Organize your paperwork and track ongoing staff education to prepare for your next AAAHC survey.

Before the survey, Cape Girardeau (MO) Outpatient Surgery Center staff 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

    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 Cape Girardeau's 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. 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.

    The surveyor recommended that the center do the following:

  • Develop a formal policy on advance directives. The center only performs elective procedures with minimal risk, and therefore does not honor advance directives. The surveyor suggested the center tell patients in writing that it does not honor advance 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.



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