Each year, several ASC accreditation organizations analyze data from their surveys to identify areas of high and low compliance with their standards. Two resulting 2018 reports, one from the Accreditation Association for Ambulatory Health Care (AAAHC) and one from the Healthcare Facilities Accreditation Program (HFAP), single out many of the same deficiencies commonly cited in Medicare deemed status and non-Medicare deemed status facilities. Areas with room for compliance improvement include quality improvement studies, credentialing and privileging, documentation management, history and physicals, cleanliness of the environment as it relates to infection control, and life safety code.

In this article, surveyors from AAAHC, HFAP, and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) share their insights on the reported areas for improvement as well as standards updates that have been challenging for ASCs.

Quality Improvement Studies

A written “quality program” or “quality improvement program,” mandated in some form by all standards governing ASCs, is the backbone of a compliant and safe facility. The program is supposed to specify quality indicators and performance measures the ASC will use to monitor its clinical and administrative activities, lower its risks, and improve its outcomes. To demonstrate that it’s making ongoing improvements, an ASC must conduct quality improvement studies. Kris Kilgore, RN, BSN, is an AAAHC surveyor and administrative director at Grand Rapids Ophthalmology Surgical Care Center in Michigan. As she explains, an ASC should perform a quality improvement study whenever a problem is continuing or recurs, an aspect of performance falls below a national benchmark or self-set parameter, or a member of the ASC team identifies a problem or potential problem. “An issue I’ve cited as a surveyor is a quality improvement study that doesn’t specify a measurable goal,” she says. “It can’t be considered a study if there’s no measurable goal that allows the organization to know it has improved. I also surveyed a center that was using quality monitoring as a quality study. This is also not acceptable because no corrective action was identified. In fact, no corrective action was necessary because the center was performing better than its stated goal.”

Kilgore shares an example of a quality improvement study her ASC performed. “The retina surgeon stated to me that not all nurses were prepping eyes for surgery in the same way,” she says. “This was unexpected because it was counter to our set anti-infection policy and procedures. Observing our procedures to determine how eyes were actually being prepared and re-educating the relevant parties toward the goal of consistent adherence to our protocols, we were able to report a meaningful study.”

Paul L. Schnur, MD, FACS, retired chief of plastic surgery at Mayo Clinic Arizona and a surveyor for AAAASF, acknowledges that quality improvement standards can be challenging.

“I recommend one person in the facility research what other facilities are doing and what is being taught in continuing education courses to set up a robust quality improvement program that always has several studies in progress,” he says. “A quality improvement committee can also be formed to make suggestions on how to improve patient care.”

Don’t forget that services related to patient care that are provided for the ASC by contract must also be included in the quality program, says Michele Kala, RN, MS, a compliance educator and surveyor for HFAP. “Centers are frequently cited for a deficiency in complying with this standard because contract service performance measures have not been developed or reported through the quality program to the governing board,” she explains. For example, the ASC must have an agreement with its outside lab that biopsy results are to be provided within a certain time frame. And it must have an agreement with its dictation service that transcriptions are delivered within a certain time frame and with no higher than a set error rate. The ASC must monitor and ensure the expectations are met.

Credentialing and Privileging

Credentialing and privileging, which are distinct but intricately related standards areas, have also been noted as having relatively low compliance. Credentialing, which is required to include peer review to ensure competence, is validating providers’ qualifications to offer healthcare services. Privileging is the process through which the ASC’s governing body approves individual providers to perform specific treatments or procedures or to use specific equipment. In addition, members of the medical staff — physicians as well as nurse practitioners, physician assistants, and nurses who aren’t employees of the ASC — must be recredentialed/reappraised at designated intervals. As Kala explains, “No one can come into the ASC and provide medical services without having their credentials reviewed. The appointment cannot exceed the designated time frame or the facility is noncompliant. The surveyor looks for the previous appointment letter in the credentialing file and checks that the current reappointment occurred within the time frame prior to expiration of privileges. The surveyor also reviews minutes from governing board meetings to ensure they document the reappointment and that the meeting date matches the letter of appointment in the credentials file. Facilities tend to do a good job of initial credentialing but fall short with timely recredentialing/reappraisal.” Adds Kilgore, “It’s also not uncommon for an ASC to be cited as deficient because it adopts a new procedure or piece of equipment and fails to add it to the privileging list.”

Dr. Schnur points out that AAAASF requires its surveyors to examine 50% of a facility’s personnel records. “All physicians, physician assistants, nurse practitioners, and anesthesia providers are considered medical personnel,” he says. “This means the ASC’s records must include documentation of a long list of items, including their required inoculations, date of employment, job description, continuing education, resume of training, and training for hazard safety, bloodborne pathogens, universal precautions, and fire safety.”

Documentation Management

For many standards, written documentation is a surveyor’s primary source of confirmation that an ASC is meeting a requirement. With so many activities needing to be documented, it’s perhaps not surprising that documentation is an issue in accrediting bodies’ quality analyses. “Although ophthalmic ASCs’ area of practice is limited, their need to adhere to accreditation/certification and documentation standards is not,” says Monte Jay Goldstein, MD. Dr. Goldstein is a surveyor for CMS and AAAASF, anesthesia chief for the Jandee Anesthesiology Division of Envision Healthcare, and medical director at Ramapo Valley Surgical Center in New Jersey. “Just one indication of the broad scope of requirements is that CMS mandates all patients have a comprehensive history and physical examination within 30 days of surgery in an ASC, and it has to be updated on the day of surgery to ensure nothing has changed,” he says. And, as Kilgore notes, “Documentation of the history and physical as well as other preoperative studies, such as the eye exam, must be incorporated into the ASC’s clinical record, not only in the records of the physician’s office.”

As further explained by Joel H. Paull MD, DDS, PC, attorney, surgeon, and AAAASF surveyor, “A complete history and physical is no less mandatory in an ophthalmic ASC than in a hospital, and it requires due diligence in questioning the patient. For example, when a patient is going to receive any form of sedation or medication other than local anesthesia (presuming he or she isn’t allergic and has no untoward reaction to local anesthesia), you must question the risk, thus documenting that it’s safe for the patient to undergo the procedure in the ASC setting.”

Kilgore offers these tips for proper documentation overall:

• Use the standards manual as an open-book test to organize and update documentation (a copy of each chapter can be given to the applicable members of the team for review).
• Keep a spreadsheet of when important items expire to make sure documentation is always current.
• Keep a calendar for drills and committee meetings so they are not forgotten.

Kala advises that all compliance efforts tie back into the ASC’s governing body and that its actions must be documented properly. Therefore, she recommends facilities develop a meeting minutes template that lists and prompts all of the topics the board is required to discuss and reflects that the discussions occurred. She continues, “The most important advice I can give is to organize compliance documentation in a way that allows for a reduced stress environment during the survey. The better organized a facility is, the easier it is for the surveyor to determine compliance. Well-prepared facilities find the survey process fairly stress-free and have fewer citations. The most prepared facilities I have surveyed have organized their documentation around the manual chapters, either paper-based or in a digital spreadsheet.” Dr. Paull concurs, saying “I once surveyed a facility that had 10 notebooks, one for each area of the AAAASF standards, laid out in the exact order. The ones that seem redundant appeared in all the appropriate places. It was wonderful.”

Life Safety and Emergency Management

Based on the accrediting organizations’ analyses and the experience of surveyors, two standards areas updated recently — life safety and emergency management — are proving to be compliance challenges for surgical centers. The new HFAP chapter on life safety, for example, contains 64 standards based on the 2012 edition of the NFPA (National Fire Protection Association) 101 Life Safety Code, Kala says. She mentions that “Typically, we see ASC leadership teams focused on the clinical aspects of standards compliance, which can result in a lack of awareness of the building safety standards and facility compliance issues that are more engineering-related.” Kala says frequently cited issues relate to generator maintenance, exit light placement and function, fire wall integrity, and fire suppression and alarm system maintenance. To inspect firewalls, she goes up on a ladder to look down from the ceiling. She says a common firewall violation stems from breaches created when holes are drilled to run phone or computer cable and they’re not filled with fire-resistant putty. Generator maintenance is another oft-cited deficiency. “Testing of the emergency power generator, including battery level, is a weekly requirement,” Kala says. “The required monthly or annual load testing is often missed.”

Many life code standards require the use of an outside contractor or facilities manager, which can be a source of noncompliance, Kala explains. It’s not that a contractor can’t or shouldn’t be used, but, she says, “The service companies may be delinquent in the way they present their test results and document what they’ve done. The ASC leadership needs to be astute enough about the requirements to convey what it needs for compliance and hold the contractor accountable for providing it.”

Emergency management standards have been added within the past few years to many accrediting organizations’ manuals, mandating ASCs to have an emergency preparedness program. “Facilities must create an emergency management program that is coordinated with its community’s plan and details how it will respond to potential facility hazards so that human and physical resources are protected and business operations are maintained,” Kala says. “Compliance requires that a staff member is assigned to design and coordinate development of the program. Noncompliance is most often due to lack of defined accountability. Similar to life safety standards, because emergency standards aren’t directly clinical in nature, the attention given to achieve compliance is frequently inadequate, resulting in citation of deficiencies.”

Kala notes that a compliant emergency management program requires multiple components, including a hazard vulnerability analysis and a plan for emergency operations, evacuation, and communication. The communication plan should detail how staff and local emergency services and hospitals will be notified in the case of an emergency event. Additionally, the ASC and the relevant community entities must have a plan for communicating back and forth to support each other through the problems.

“The ASC must train staff and physicians on the program, and the program must be tested at designated intervals,” Kala adds. “The required mock disasters can be done in conjunction with the hospital with which the ASC has a patient-transfer agreement. Finally, the results of the testing have to be critiqued. Did all elements of the plan work as expected, or is there a policy or procedure that needs to be changed? The surveyor will look for those critiques.”

Yes, the Standard Applies to Your Surgery Center

Dr. Paull cautions that ASCs should never think they needn’t pay attention to each and every standard.

“They can’t think it’s not necessary to address ‘issue x’ because ‘we don’t deal with that,’ ” he says. “That’s not the case. If there is a standard about a topic or issue, the facility needs to comply. For example, if your facility doesn’t treat pediatric patients, you must have a policy stating that to be compliant.”

Dr. Goldstein agrees, reinforcing that “the governing body and staff should never assume a standard doesn’t apply to them. Preparation for survey should always be in progress. If for some reason there is a lack of understanding of a standard, seek out additional resources, of which there are many, for assistance.” ■