By Lorrie Cappellino, RN, MS, CNOR, Surveyor, Ambulatory Health Care
In 2021, The Joint Commission is conducting a high number of inaugural surveys.
Some are newly minted businesses; others have returned to The Joint Commission after changing accreditation courses and others are long-standing ASCs under new leadership. Whatever the reason for the inaugural survey, we survey more than 1,100 ASCs annually so we’re more than familiar with the ambulatory environment.
Our surveyors are familiar with the ins and outs of the ASC industry, as they have prior clinical experience in specialties including surgery center administration, nursing, process improvement, dentistry, surgery, radiology and anesthesia. Joint Commission surveyors have been in your shoes and their goal is to provide a meaningful, individualized assessment for each ASC setting.
That said, we have several tried-and-true tips to make the survey experience run smoothly.
The best starting point may be to gather and study resources that detail quality and safety processes and standards. ASC leaders can begin with accessing the dedicated ASC web page, which explains the survey process.
Request a Free Trial of the Standards
The Joint Commission offers a 90-day free trial e-dition to the electronic version of our standards. Take advantage of this! We cannot stress this enough.
This online document is searchable by both chapter and keywords. If your health care organization is seeking deemed status through The Joint Commission, the E-dition’s clear annotations regarding those requirements are helpful.
The standards manual Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) is also available for purchase.
ASC leaders should pay particular attention to the following chapters of the CAMAC manual. They should evaluate the information, line-by-line to ensure every “t” is crossed, and “i” is dotted as they work toward their first survey experience.
The recommended CAMAC manual chapters to review are:
- Infection Control: Reviews sterilization and high-level disinfection (HLD) management, including the monitoring of time, temperature and pressure of biologic testing; documentation; and solutions used for decontamination, HLD and housekeeping in accordance with IAW clinical practice guidelines.
- Environment of Care: Covers sterilizer/HLD equipment maintenance and cleaning; temperature and humidity management; and air exchanges and pressure in operating rooms (OR), decontamination rooms and rooms where sterile supplies are stored.
- Human Resources: Includes competency assessment for those working in sterilization to ensure the process makes sense (e.g., documentation of qualified trainers and oversight; frequency of training/competency assessments; and how to ensure waived testing is accomplished and cultural diversity training is available for all).
- Life Safety: Reviews fire safety, including attention to detail with extinguisher, exit and fire door checks and maintenance; and how to effectively time, implement and post-evaluate fire drills that include all employees (i.e., licensed independent practitioners) in plan.
- Record of Care: Ensures anesthesia and surgeon patient assessments are completed and documented in adherence with national, state, local and practice and policy guidelines.
- Medication Management: Covers sound processes related to medication order sets, commonly confused and high alert medications, medication security, and the avoidance of diversion.
In addition to the manuals, there’s a plethora of online resources for ambulatory health care organizations pursuing accreditation. For a big picture outlook, review the 2021 National Patient Safety Goals and the monthly newsletter Joint Commission Perspectives.
It’s also worthwhile to check out online resource centers on emergency management, physical environment and environment of care.
Delegate Survey Preparation
In my 30 years as an OR nurse and later a Joint Commission ambulatory health care surveyor, I’ve observed that most senior leaders maintain overall oversight but designate “chapter champions” or teams to address critical details of National Patient Safety Goals and each of the 14 chapters of the CAMAC. These individuals conduct self-assessments and gap analyses before developing and creating processes to ensure they meet standards.
ASC leaders also often conduct their own “mock” tracer activities to evaluate processes, identify risks and ensure continuous quality and safety for patients, staff and visitors. A mock tracer essentially follows a patient through the entire experience from check-in through discharge to offer a detailed look at workflows. Effective ASCs leaders encourage and assign current and new staff members to use “fresh eyes” to conduct mock tracers to help identify areas of risk.
As important as delegation is, physician involvement is critical to survey success. For example, surgeons and anesthesiologist can evaluate:
- the oversight of standing orders
- determining what items are stored on a crash cart
- patient selection criteria
- emergency management decisions and policies
- process improvement activities.
Review Frequent Citations
Most of ASCs’ commonly cited opportunities to improve fall within the areas of Infection Control and Medication Management.
Below are examples identified as high or moderate risk and likely to cause harm to patients, staff or visitors.
Frequently cited infection control issues:
- lack of documentation regarding sterilizer biologic testing
- failure to follow manufacturer’s instructions for use regarding mixing chemical disinfectants during instrument decontamination
- non-compliance with OSHA requirements while transporting used surgical instruments
- non-compliance of hand hygiene with selected clinical practice guidelines
- frequently cited medication management issues:
- failure to label high-alert medications in accordance with organizational policy
- two or more medications ordered for the same indication (such as pain)
Keep in mind that during survey, The Joint Commission is not focused on minor details like dust bunnies, but rather particulars of heightened importance relevant to an ASC’s specific high-risk areas.
Remember, we are here to answer your questions. Please email if we can help with your inaugural survey!
Lorrie Cappellino is an Ambulatory Care Surveyor with The Joint Commission. She has extensive surgical suite and executive health care leadership experience and is a certified perioperative registered nurse.