By Susan Annicelli, MSN, MS, RN, Field Surveyor
It’s been a full year since The Joint Commission returned to surveys at full capacity and, as expected, most high-risk findings at ambulatory surgery centers (ASC) are related to infection control, medication management and leadership.
Challenges actually mirror those of 2019, despite two very difficult years in terms of:
- supply chain
- scope of services
- regulatory/statutory requirements
My colleagues covered the top ambulatory healthcare challenges for 2021 in their year-end blog post and it’s really an excellent read full of insights from Joint Commission experts in standards interpretation, physical environment and infection control.
My goal today is different as I hope to offer my perspective on steps accredited organizations can take to avoid a finding in the first place.
1. . Establish a point-of-contact for The Joint Commission survey. The single most important piece of advice I offer is to always appoint a “point person” to shepherd the organization through the survey. This individual’s main responsibilities include:
• managing the application
• communicating with The Joint Commission’s account executive
• coordinating the survey event
This sounds like a full-time job in itself but it’s actually much easier to delegate if a central point person takes ownership of the whole process.
2. Identify all standards, elements of performance and documentation requirements that are aligned with the type of accreditation survey requested. This ultimately makes survey preparation easier because you’re only reviewing the applicable items.
3. Familiarize staff with the tremendous resources available to ASCs via The Joint Commission’s secure extranet and dedicated ASC webpage. I can personally promise you that many of the answers you need are on the website and reviewing these resources will save a lot of time.
4. Ensure current and up-to-date documentation of policies, plans, testing logs and all personnel/privileging files. Documentation is a significant component of a Joint Commission survey and it pays off in dividends keeping it as current as possible.
5. Invest in education and familiarize front-line staff with the survey process. Even though we recommended a point person, there are a lot of opportunities for the entire patient-facing staff to interact with the surveyor. Mock tracers, interviews and rehearsal activity will reduce a great deal of staff stress during the survey process.
6. Anticipate surveyors will utilize a hierarchy approach in assessing infection control requirements with top-to-bottom flow from regulatory requirements to conditions for coverage (CfCs) to manufacturer’s instruction for use to evidence-based guidelines to consensus documents to organizational policy. Be sure to review The Joint Commission’s Infection Prevention and Control Hierarchy in advance of the survey.
7. A common saying at The Joint Commission is ”There are no perfect healthcare organizations.” In that spirit, be prepared to discuss a process improvement initiative your organization has undertaken that involves data collection and analysis as well as assessment of the culture of safety within the ASC.
8. Encourage open and candid communication among staff, leaders and the survey team. A common misperception is that only the C-suite talks to the survey team. This is not the case! Joint Commission surveyors welcome learning about the challenges and opportunities of the ASC from staff at all echelons.
The accreditation and survey experience really does get easier over time. Our long-time accredited ASCs always say that accreditation “work” is best spread out over the year, rather than in a panic right before the survey. Keeping accreditation—and especially the high-risk findings that are causing headaches for other ASCs—top of mind is key to a smooth survey visit!
Susan Annicelli, RN, is a Field Surveyor at The Joint Commission.