OASC | INSPECTIONS

Planning Ahead

PREPARE FOR INSPECTIONS WITH THIS COMPREHENSIVE CHECKLIST

By Virginia Pickles, Contributing Editor

Any entity involved in direct patient care is subject to periodic inspections by government agencies and accrediting organizations, sometimes without advance notice. Armed with checklists and worksheets — and 166 pages of conditions for coverage when CMS certification is on the line — representatives from the state department of health hold the fate of an ASC in their hands.

Seeing a team of surveyors at your front desk, ready to examine every facet of your operation, can be intimidating, even in the most buttoned-up ASC, says Maria Tietjen, RN, BSN, executive vice president of nursing and clinical services for American SurgiSite Centers. “When the surveyors come in the front door, some people want to run out the back door,” she says. “But as long as everyone has been doing his or her job properly — and your good outcomes and positive patient feedback will confirm this — then a deficiency-free survey is just a matter of making sure everything is in order.”

In the same way you prepare for unplanned occurrences, such as surgical complications, equipment malfunctions, and power outages, you can also plan how you will respond to an unannounced visit from CMS surveyors. Tietjen, who manages and works with nine ophthalmic ambulatory surgery centers on the East Coast, offers the following advice for minimizing survey-induced stress before, during, and after the visit.

 Make ‘By the Book’ a Habit

A surgery center’s Policies and Procedures Manual outlines every aspect of day-to-day operations. It covers, in great detail, everything from infection control and medication management to environmental conditions and patient privacy. It is based on best practices sanctioned by leading authorities, and approved by your ASC’s governing body. Importantly, it reflects the conditions for coverage set forth by Medicare to run a surgery center, and these conditions form the basis for much of a surveyor’s evaluation.

“One of the top reasons for a surgery center to fail a survey is to not follow its own policy,” Tietjen says. “That’s why my best advice is to make sure your practice — everything you do — reflects what’s written in your manual. If you change how you do something or bring in a new piece of equipment, be sure to update your manual.”

Equally important is your ability to follow your policies. “If a policy is impossible to follow — perhaps a requirement that every patient must have a preoperative EKG — it needs to be revised or eliminated,” Tietjen says. “For example, modifying the EKG requirement to include only patients who are a certain age or older or those who have a history of heart disease will help ensure that it will be followed.”

 Regularly Update and Organize Files

Surveys follow a predictable format. In addition to a tour/inspection of your facility and observation of selected patients and their surgeries, surveyors will perform a document review. This is where organization pays off. “When you feel that authorities are looking at you under a microscope, and they ask you for all kinds of documentation, it’s easy to end up running around, grabbing reams and reams of paper, but still feeling like you’re missing something,” Tietjen says. She notes that, in addition to your Policies and Procedures Manual, you should be prepared to produce:

• Minutes from all meetings of your governing body and medical staff, as well as any meetings that focus on quality assurance, infection control, and patient safety;

• Selected personnel files, including those of physicians, to ensure they are properly credentialed;

• Medical records/patient charts;

• Vendor contracts;

• Environmental rounds, and so on.

“All of your paperwork should be labeled, sorted, and neatly catalogued in binders,” Tietjen says. “When the surveyors ask you a question, not only should you know the answer, but you should also be able to easily locate the supporting documentation.”

Respectfully Disagree

If you’ve ever disagreed with a surveyor’s report, Tietjen can empathize. “I received a deficiency notice with instructions on how to correct it,” she recalls. “I disagreed with the amended policy, because I knew it was not feasible for us to follow. So I did some research, surveyed other centers, and sought advice from members of the Outpatient Ophthalmic Surgery Society. I learned the department of health was asking us to do something that wasn’t being done at any other facility.” As a result of her appeal, which included strong supporting evidence, the deficiency was removed from the report.

“I have been told by surveyors, ‘If you disagree with something, ask for the regulation,’” Tietjen says. “If they can’t produce it, then you can explain your rationale for doing something in a certain way and cite the organizations that support your process. If you arm yourself with knowledge and question them respectfully, you have a good chance of being heard,” she says. “In my opinion, surveys help keep our surgery centers operating without problems.”

 Take an Objective Look at Your Center

When surveyors arrive at your surgery center, even before they’ve introduced themselves, your survey has begun. You may not even know they’re in the building but they’ve already started inspecting the premises with critical eyes. Although your operating suite and other patient care areas receive the most attention, Tietjen recommends you regularly take an objective look at your reception area — where that all-important first impression is formed — to make sure it’s clean, neat, and free from any hazards that could trip or injure a patient or staff member.

The environmental surveyor will inspect the entire physical plant, including important safety features, such as:

• Fire alarm and sprinkler systems, fire extinguishers, fire walls, and doors;

• Emergency generator system, including battery backup;

• Emergency lighting and exit signage;

• Emergency exit access.

Even seemingly minor things, such as placement of your hand sanitizers, will not escape inspection. (Tip: Do not place them over an ignition source or a carpeted area without a fire suppression system.)

 What to Expect on Survey Day

The survey team consists of several individuals with expertise in different areas and may include a physician, a nurse, a pharmacist, an infection control specialist, and a life safety code surveyor. (See “Focus on Infection Control,” page 7.) Typically, they hold an entrance conference to introduce themselves, explain why they are there, and share what they will need.

From a practical perspective, Tietjen recommends offering the surveyors a comfortable room with a phone and staff directory, so they can contact key staff members directly when they have questions. Your administrator or clinical director will likely be the point person for the surveyors; however, the entire team must be prepared to provide information and answer questions during the survey, which can span 2 or 3 days. They may need some reassurance that they should continue doing the good work they do every day.

“The only thing you have no control over is how staff members will respond during a survey,” Tietjen says. “People get nervous when they know they’re being watched. They may make a mistake or forget something, but usually those are small infractions that are easily corrected and are not a problem.”

At some point during the visit, the surveyors will select one or two patients to follow from admission through discharge. With the patient’s permission, they will observe each step of the process: preoperative preparations, how instruments are processed, the surgery, postoperative care, and delivery of discharge instructions to the patient. Surveyors may chat with patients and ask them questions about their experience, and they may query staff about policies and procedures.

“They may ask a patient if he or she was happy with everything,” Tietjen says. “They may ask a staff member about a specific aspect of the surgery, or they may ask a more general question, such as ‘How are fire drills run here?’ or ‘How do you handle medication shortages or backorders?’ Then they compare the answer to what’s written in your policy manual.”

Tietjen helps staff prepare for the unpredictability of a survey by periodically holding mock surveys. “Sometimes during a site visit, I’ll announce, ‘Today, I’m a surveyor. Show me this. Show me that,’” she explains. “Constantly practicing gives staff members confidence, so they’re ready for the real thing.”

 Dealing With Deficiencies

Generally, the results of a survey are revealed during the exit interview, and a written report follows shortly thereafter. If deficiencies were found, a “plan of correction” must be submitted within 10 days. (Note: You can disagree with a deficiency. See “Respectfully Disagree,” page 8.)

“Depending on your state’s regulations, you may be required to include evidence of corrections,” Tietjen says. “For example, department of health surveyors may want to see that an in-service has taken place related to any policy change, or they may want to see an invoice showing that certain work has been performed to bring the facility into compliance.

“Your plan of correction should include the name of the person or persons responsible for correcting each deficiency, who will oversee it, how it will be done, and what you will do to prevent it from happening again,” says Tietjen, who recommends that you create a log to document your progress. “Follow-through is important,” she says. “If you don’t correct your deficiencies, you risk losing your CMS certification.”

Once you have corrected all deficiencies and are in compliance, the surveyors will approve your plan of correction and return to inspect your center again.

 Plan for the Next Survey

After you correct deficiencies and receive approval, you may be tempted to rest on your laurels. Don’t do it.

“Three years fly by quickly,” Tietjen says. “You should always be planning ahead and doing the required work in anticipation of the next survey. So when the surveyors walk in the door and say, ‘Here we are,’ you can calmly say, ‘Hello. Would you like a cup of coffee or a bagel while I gather our paperwork for you?’” ■

MARIA TIETJEN, RN, BSN, is executive vice president of nursing and clinical services for American SurgiSite Centers. She can be reached at mtietjen@americansurgisite.com.