• E-mail
• Print
• RSS

Check out these top hot spots from an AAAHC survey

Ambulatory Safety Monitor, May 26, 2004

Want to receive articles like this one in your inbox? Subscribe to Ambulatory Safety Monitor!

Two AAAHC surveyors arrived without warning at the Yakima (WA) Ambulatory Surgery Center last September. Their visit was for the center's second triennial accreditation survey, but also counted as a deemed-status visit for Medicare reimbursement.

Despite the unannounced arrival, staff knew surveyors could show up anytime in September, and they were prepared. Staff leaders from various departments reviewed AAAHC's new standards and reported their findings on governance and credentialing changes during the board of directors meetings and noted changes to the clinical standards during clinical review meetings, says Scott Faringer, CASC, the center's administrator.

Tie peer review to credentialing
Credentialing was one of the survey's main focuses, says Faringer. Surveyors pulled credential files from each of the center's specialties, verifying that leaders

• perform appropriate background checks
• incorporate peer-review data when recredentialing staff
• document how they use peer-review data during recredentialing

Surveyors also checked clinical-staff credential files, making sure leaders update staff skill levels regularly.

The medical director also reviews patient charts when patients have complications in the recovery room or postoperative complications, such as infections or excessive pain after surgery. The director makes notes in physicians' credential files when he reviews their charts, says Faringer.

Check the safety of your facility
Surveyors also focused on compliance with the Life Safety Code (LSC). Before the survey, the center asked the owners of the building to walk through the facility with an LSC checklist to make sure there were no major structural problems, says Faringer.

Surveyors took a tour of the facility and checked for the following:

• Gas supplies and emergency generators
• Logs indicating how often the center tests its generators
• Storage of supplies, to make sure they weren't too close to the ceiling or to fire sprinklers
• Service dates for medical equipment and utilities

Surveyor suggestions
Surveyors recommended staff create a patient-suggestion box and leave it in the lobby. They also suggested that staff enter the names of patients who return patient-satisfaction surveys into a raffle and award gift certificates and prizes to boost the number of patients who complete the surveys. They also wanted the center to conduct at least four quality-improvement studies annually, says Faringer.

Want to receive articles like this one in your inbox? Subscribe to Ambulatory Safety Monitor!

• E-mail to a Colleague
• Print
• RSS
• Archive