Inspection at Your ASC: Through the Eyes of a Surveyor
It’s a Monday morning and three well-dressed people with wheelie luggage just showed up at your ambulatory surgery center’s reception. It’s your turn to get surveyed.
Surveys from accreditation bodies can be stressful for the ASC’s staff and administrators. But there are ways to have peace of mind during inspections. One of the ways is by listening to experts’ advice.
In our recent webinar, Inspection at Your ASC: Through the Eyes of a Surveyor, dr. Biraj Patel and Ashley Poulos talk to an ACHC surveyor and an ASC consultant, Toya Brown, about how to achieve a successful survey.
You can listen to the full discussion on the PreferredMD Youtube channel or read crucial excerpts below.
What is accreditation and why it’s important?
Toya Brown: Accreditation is the measure of the quality of the health services provided to the community. It's a commitment to that community that you're going to provide high-quality patient care. It's often required by the federal government because you want to build Medicare or Medicaid, as well as some insurance companies require it. Ultimately, it reduces the liability and risk to the center when they follow the standards.
Ashley Poulos: Is it required, if a facility is not going to be going through insurance or Medicare, to become accredited? Or is it just an industry standard that we should be doing at this point?
Toya Brown: It's an industry standard, at that point, for that group. But I think that everybody wants to have accreditation. You want to assess your risk and liability, as well as ensure you're providing great patient care to your community.
To deem or not to deem
Ashley Poulos: Well, once we're looking to be accredited, what are some of the first steps we should take?
Toya Brown: There are some accrediting agencies out there, ACHC, also known as HFAP, AAAHC, QUAD A, a Joint Commission, and others. Once you've picked the accrediting agency you wish to work with, you then decide if you want to do a deemed status or a non-deemed status survey.
Deemed status is when the surveyors come on site, they have CMS deeming authority, and they survey your center using CMS standards, as well as the accreditation standards.
Whereas with non-deemed, the surveyors evaluate the center using the accreditation standards.
Ashley Poulos: Is there a reason why a facility would go one way or the other for their inspection?
Toya Brown: As an administrator for myself, I liked the deemed status because I could knock out two surveys at once versus having to do one survey and then wait for CMS to show up. So I prefer the deemed status, it was just easier for me as a leader.
Ashley Poulos: Is there a difference in the standards from an OBS to a facility?
Toya Brown: Usually, the OBS’ and surgery centers’ standards are pretty similar because you're providing surgery to a patient and you still have the same infection control and other processes that need to be followed in order to maintain compliance.
Ashley Poulos: If you’re going through the deemed route, do you have to reach out to CMS directly or is that handled all through the accrediting agency?
Toya Brown: You'll still have to fill out applications for CMS, but the accrediting company typically communicates with CMS and lets them know who is up for a survey.
Initial vs. re-accreditation survey
Ashley Poulos: What is the difference between the initial and the reaccreditation surveys?
Toya Brown: The initials are the first time that the survey agency is going to the surgery center. They tend to be a bit less stressful because the business hasn't been operating as long, so there are fewer documents that need to be reviewed. But there is a strong focus on how the governing body is going to be accountable for all aspects of the ASC.
Re-accreditation is a review of the last three years of operations at the surgery center. It's an in-depth review of the center to see how the center is meeting compliance with the standards. This is typically done through observation, inspection, document review, and interviews with the staff and team leaders.
Ashley Poulos: How far in advance would we schedule the inspection? What's the time frame once we're set up to do the inspection?
Toya Brown: You want to be survey ready, ideally, all the time, but I know that can't always be the case. So as soon as you know that you're going to be due for a survey, or if it's an initial, you want to start working on it right away.
With reaccreditation, I typically say nine months to a year because you want to make sure all meetings discuss those key requirements that are in your standards.
Ashley Poulos: At any time, if there is a scheduled inspection, will they be informed of the date or is it always unannounced?
Toya Brown: Deemed surveys are unannounced surveys. We're not allowed to give dates, but the benefit of that is that you put in blackout dates. Typically, you can put in your portal when you won't be available for the survey and we try to avoid them.
Ashley Poulos: Would a non-deemed have a scheduled date then?
Toya Brown: There's potential. It just depends on the center and the organization.
Ashley Poulos: Will the previous inspection be taken into consideration during a re-accreditation inspection to evaluate its outcome?
Toya Brown: Yes, the surveyors have the ability to review all documents. If the center was surveyed with the same accreditation company, I have access to all the documents from the previous survey. Then, I focus on their plan of corrections. So, when I conduct the survey, I assess that as well.
Ashley Poulos: Does this carry more weight in the survey, or is it evaluated across the board?
Toya Brown: It's evaluated across the board. As surveyors, we have a lot to cover. So, I typically cover all aspects and then verify that an ASC has resolved the issue from the previous inspection to ensure compliance.
Ashley Poulos: Is it possible that they can go beyond the last inspection and look at all of our plans of corrections?
Toya Brown: If you've stayed with the same accreditation company, they have the ability to look back, but things change so frequently nowadays that I typically look at the last one and then I survey the entire center on all of the standards anyways.
Ashley Poulos: You mentioned the governing body. Who is involved with the governing body?
Toya Brown: The governing body is typically the medical director, the owners, other physicians, maybe the anesthesiologist, and pretty much anybody who participates in the governing board meetings.
Ashley Poulos: So it's really important to get them on board when we're getting set up for our inspection?
Toya Brown: Absolutely. They need to know every aspect of when the inspection is coming and what to plan for. Especially if they're clinical leaders or they work in the surgery center, they too need to be aware of the standards.
Sometimes, I would struggle with meetings because physicians do not always want to hear extra information. However, it is essential that they understand what is happening in their business so that I can make decisions that are in the best interest of them, their patients, and their company.
Ashley Poulos: Should we begin preparing within the 6 to the 9-month timeframe you mentioned?
Toya Brown: Nine months to a year. Based on your experience as an administrator and if you've been through surveys, you may not need as much time as others, but I say safely a year just to make sure that you get in everything you need to in those key meetings with those owners.
Preparing for an ASC accreditation survey: Tips
Know and share the standards
Toya Brown: I’ve been to certain areas where the leadership team has not reviewed the standards. It's kind of a red flag to me because I know that I'm going to find non-compliant matters since they haven't seen the standards. So it's crucial that everybody who is going to participate in the survey reads the standards.
Share the Emergency Operations Plan and the Hazard Vulnerability Assessment
Toya Brown: Share the emergency operation plan and the hazard vulnerability assessment with emergency outside leaders. It can take some time to figure out who you're supposed to send that to and then even get a response back from them.
Review personnel and credentialing files
Toya Brown: If you take time to look at your standards, you can create a checklist or an audit list from your standards, then you can go through your files and make sure you have everything per your standards.
Get all documentation in order
Toya Brown: Match up your documentation with the standards whenever possible. It makes it easier to show compliance to the surveyor and you’ll also look organized, and being organized is key in a survey.
Ensure policies match the work performed in your center
Toya Brown: Next, you want to review your policies and make sure that your policies match the work that's performed. I've worked with an eye center that had some sterile processing policies that talked about scope washing. And I had to let them know that, although it was a good policy, it did not match their center and they need to remove it because it doesn't fit what they do.
Know which of your standards state Condition for Coverage
Toya Brown: Lastly, know which of your standards state the condition for coverage (CFC). The CFC standards, or conditions, are set by the federal government and are required in order for you to be operational. So citations could lead to immediate jeopardy, which could lead to your center being shut down until you fix those conditions. Those are the ones you just don't want to mess around with.
Biraj Patel: Can you give us some examples of the CFCs?
Toya Brown: Sure, like governing board accountability is a must. The governing board must be accountable for all aspects of the surgery center. So lack of governing board meeting minutes or even QAPI minutes could lead to that being deficient in that standard.
Biraj Patel: Remind us, how frequently should the governing board meet?
Toya Brown: It’s up to the center, but at minimum, I say four times a year, or quarterly. I know some centers that do them monthly so as not to bombard people with so much information at once. So you're definitely open to the time frame. You just need to be having those meetings and having minutes to show it.
Ashley Poulos: Where would we find CFC standards?
Toya Brown: You can find the condition for coverage and the standards you receive from the accrediting agency, as well as the government. You can look for the standards in their Appendix L online.
Conduct a mock survey
Toya Brown: I also think it's important to do a mock survey to find out what things you're deficient in so you can start fixing them right away. I once had a mock survey done at my center and I found out that a physician was dictating his case before he even did the procedure. And I was able to address that with him immediately and stop him from doing that before the real survey because I would have gotten a citation for that.
Ashley Poulos: Was it because it was done electronically so you could tell it was stamped ahead of time?
Toya Brown: Yes, that's exactly what it was. So audit your medical records if you feel that you may have physicians who are non-compliant in the H&P or non-compliant in the heart and lungs. You want them to do what they're supposed to do to be successful.
Ashley Poulos: As a surveyor, do you look at every little date? Is it that specific that we need to make sure that everyone's on point?
Toya Brown: Yes, absolutely. Hopefully, you're doing audits through your business office or through somebody on the team who's running audits of the charts, and looking for things like the dates and times, or if they back date or back time H & Ps. You need to be aware of that and report it to your governing body or through QAPI if you catch it.
Ashley Poulos: Could we have someone else come in to do a mock survey? Are we even able to find a surveyor that would do a mock survey for us?
Toya Brown: You can hire surveyors to do a mock survey for you. Keep in mind that if you have a surveyor or consultant like myself who does your mock survey, I would not be your surveyor on the day of the real survey. We do not allow that to happen.
Ashley Poulos: Outside of a mock survey, what would a consultant be able to help us with as far as getting prepared?
Toya Brown: There's a lot a consultant can do to help a center get ready for surveys. I write policies, I do audits for sterile processing, medication, and other things.
Ashley Poulos: What would be the ideal time frame for us to have a consultant come in and help out?
Toya Brown: The more time, the better, because I can touch more areas of the center if given the time to do so.
Technology for facility document management
Ashley Poulos: A lot of what you talked about pertains to paperwork, like the credentialing files, the documentation, and even the facility documents. Have you seen a transition to electronic or to platforms rather than having paper binders for all the paperwork?
Toya Brown: Yes, I do see technology coming to the industry, such as PreferredMD, I see it being used for credentialing, logs, etc. There's a lot of value in technology and anytime you can take a tablet and knock out a log real quick and then show it's complete, it adds so much value to a leader because it's in the system and can be easily found.
Also, I like when the systems provide alerts. There's so much equipment that requires maintenance or to be at least inspected on an orderly basis. So it really helps to have alerts remind me that I need to get this or that checked.
Ashley Poulos: Have you, as a surveyor, come in and had a facility that has converted to technology, and how was that as far as the survey?
Toya Brown: When it relates to some of the documents like the logs and whatnot, they seem to be more organized with the help of technology. I've seen some binders that work out great too, as long as people line them up with the standards or know when it's appropriate to show that log or document.
Ashley Poulos: What should we do if we're transitioning to a platform? As far as all of our other paperwork, how should that be stored? Is there a hybrid system?
Toya Brown: Yes, some are hybrid systems that you can scan in the document the piece of paper, and some you can input it. What I liked about PreferredMD is that you could create your own logs and it was automatically in the system. Scanning once in a while is okay, but scanning consistently can be a bit much and time-consuming for the staff as well.
Day of survey tips
Ashley Poulos: Once we're prepared, we've done everything that we need to do, and we transition to that open window when the inspection is going to come, what should we expect when that survey hits?
Toya Brown: As a surveyor, usually, I show up in the morning and introduce myself to the front desk. My first tip is to have a designated area away from patients and staff where the surveyors can sit and where staff could enter for interviews.
Have the Wi-Fi password, surgery schedule, and staff schedule available to the surveyors. Try to free staff, that are going to be participating in the survey, from clinical duties when the surveyors need them. Staff should also have a piece of paper and a pen with them because surveyors usually share recommendations to help out the center and staff could then write those down.
Surveys are very stressful for everybody and surveyors want you to pass, but you got to stay calm throughout the process. It adds value for everybody. Know your binders, know your document system, know how to navigate there, and use a search function — it helps with the efficiency of moving through the survey when you have the documents available.
Biraj Patel: What would you say are the key staff members that need to be involved in the survey?
Toya Brown: Infection preventionist is key. Quality management, life safety officers or managers who can go through the building, can read blueprints. They are important to have available to the surveyors.
Ashley Poulos: And how many surveyors are typically a part of the inspection?
Toya Brown: Anywhere from two to four, it depends on the accreditation agency. Sometimes you'll have two nurses and one is really strong in life safety, so they will do the life safety piece. Sometimes you'll have two nurses and then one life safety surveyor. So it just depends on the accreditation agency really.
Ashley Poulos: What happens if we have an emergency? Say there's a patient that has to be transported or the power goes out. How do we handle that?
Toya Brown: With temporary emergencies, surveyors can be patient and we're flexible. So if you have to transfer and care for the patient, make sure that all documents are handled and that the patient gets to the hospital safely.
Make sure you fill out an occurrence report because most likely the surveyors will want to review it to understand the process of what happens next with that type of occurrence report. As for power outages, that can vary, just because the power could be out for a couple of hours, it could be out for a day, it just depends on when it comes back on. But if it's a big emergency, the survey may need to be rescheduled.
Ashley Poulos: And if it has to be rescheduled, will the center be penalized and have to pay an additional amount or how does that usually work?
Toya Brown: I don't think that it's necessarily a penalized area. It's just where, you know, the agency has to cover the surveyors going out and travel, so there may be an incurred cost. Fortunately, I have not had that happen in my center, nor have I had it as a surveyor, so I'm not quite certain exactly how the fees would work.
Ashley Poulos: What would your recommendation be if one of the key team members or a couple of the team members are not available? Say the administrator or the director of nursing is out. How should we come back from that and be ready for the inspection?
Toya Brown: It would just depend on who is out of the office. You do need your key players to participate in the survey to answer questions. If they’re out, the survey may be rescheduled or we can talk on the phone. I've had situations where infection preventionist was not available on-site but was available via phone. That worked well. As long as you can articulate the processes and describe your policies it should be okay to do some over-the-phone conversations.
Ashley Poulos: What is the best way to show surveyors the documents if a facility is using an electronic system?
Toya Brown: The best way to go about that is to have a large screen to which you can connect your laptop and put up your forms and documents on the large screen. That reduces people hovering over one computer to read something or reduces you having to print documents.
Ashley Poulos: If we have a consultant working with us, should they be a part of our survey?
Toya Brown: They can be a part of the survey, although they're not the leader of the survey, they can support the administrator or the director of nursing. I have worked with consultants during surveys and they were a really good support to the administrator.
Ashley Poulos: How do surveyors perceive that when we have a consultant that's working with us the day of?
Toya Brown: I actually appreciate it because the consultant is very knowledgeable and adds value to that center. So when we discuss something, they're more on my page and understand me a bit quicker than someone who's never been through a survey or run a surgery center.
What are facilities' most common deficiencies in surveys?
Toya Brown: I never thought hand hygiene would be as bad, but it still is. Other relatable offenses are failure to scrub the hub, letting prep dry, and poor medication handling practices.
The way to combat that is when you know you're having a survey, put together a cheat sheet of the things that are most commonly cited. Share that with your anesthesiologist, CRNAs, and your physicians. You could put it on a quick little note card so they can glance at it and move on. But they need to be aware that that is still a topic that needs to be improved.
- Next is a facility failing to implement an infection prevention program within the center. It could be that they're not doing patient tracking, they don't have audits, or there's a lack of involvement of infection prevention in their QAPI meetings. Also, their documentation does not meet the center's policies that they currently have.
- The next one I have on my list is HR files are often missing signatures, lack a job description, or lack governing board approval. Or they just have expired documents which haven't been updated, or documents that are incomplete or completely missing.
- Committee meeting minutes. One way that the governing body shows authority and shows accountability to the AFD is through their meeting minutes. So if you don't have meeting minutes, you're showing that there's no accountability and authority at the center.
- Missing testing on your generator, HVAC, eye washes, medical records, and H&Ps on the tracer patient are common. I've witnessed that missed heart and lung assessment. I know that doctors hate doing it, but it's a part of the rules and they just need to figure out how to put it in their practice and be successful with it. Also pre-charting is caught and then missing signatures again is a common citation.
- Failure to follow sterilization best practices. When I visit certain centers, I recognize that they have surgical techs in those roles, which is great. However, I think that somebody needs to have a certification in sterile processing to be running that department. Again, it's an area that leaders kind of misunderstand. So having somebody certified can ensure that you're compliant.
Ashley Poulos: Why do you think there's this misunderstanding with sterile processing?
Toya Brown: It's just one of those areas that are not focused on in nursing school. As a surgical tech, in school, they did talk to us about sterile processing, but we didn't really do it. You need to have some boots-on-the-ground training, as well as certification, to show that you are compliant in that area. Sterile processing, if done poorly, puts the company and patients at serious risk and it's just one you don't want to mess with.
Ashley Poulos: For all the paperwork, have you found that centers are more compliant when they do have platforms in place to have all the documents stored?
Toya Brown: I do find that they're more compliant, especially if the platform has the ability to send alerts and remind them that something is due or something is missing. Especially with credentialing. Credentialing can be a headache for most of us, so to have a platform that assists in credentialing, can send out the applications, or send out the references adds a lot of value.
Ashley Poulos: One other area I think a lot of facilities may have trouble with is the building maintenance, like you're saying, the generator, the HVAC. What is one way that we can make sure that more people know how to do the weekly, monthly and quarterly, etc. testing that we have to do and understand what it takes?
Toya Brown: Cross-training is important. It builds mutual respect between the teams when you show them what they each do to others. It also allows people to go on vacation and have time off. Most of our centers are small, we have a handful of people, the more you cross train the more support people have as well as the business has.
Ashley Poulos: Do you find that that's an issue with inspections? Not enough people understand the different monitoring that we need to do?
Toya Brown: I haven't had too much experience with people being gone, fortunately, but I feel overall as a leader, that cross-training adds more value. Because a surveyor can ask you to show them how you check the generator or how you check the emergency lights. And you need to be able to not only articulate your policy but show what you do.
Ashley Poulos: What happens after the inspection? Especially if we had various deficiencies.
Toya Brown: After the surveyors leave, you can plan to get a citation report or deficiency report from the accrediting agency listing all the citations that were found within your center. It’s crucial to share your citations with the clinical staff if it relates to their work because, ultimately, they're the ones to change their practice to make the center compliant. So they need to know what the surveyors found and the why behind it.
Surveyors are going to ask you to create a plan of corrections off those citations. It's typically due 10 days from the day you received the report. This plan is developed by the facility and it's either approved by the surveying agency or CMS that you described the actions the facility will take to correct deficiencies and the date of when deficiencies will be corrected.
Ashley Poulos: Who notifies CMS if it's approved or not approved?
Toya Brown: The accrediting agency is in communication with CMS at that point.
Ashley Poulos: Worst case scenario, say we fail an inspection. What should we do?
Toya Brown: Immediately fix whatever you're failing. If you know how to fix it, go into action right away. If you need help, reach out to a consultant. If you have questions, your accrediting agency can help guide you on some of them. They can be very helpful when you need to make some changes.
Ashley Poulos: Would it be advised to schedule an inspection or apply for another inspection right away?
Toya Brown: The accrediting agency will work with the ASC to get some type of resurvey occur. It won't be announced if it's the deemed status one, but they will work with the center to get it fixed. You have more than one opportunity to pull in wins here. It's not just that one time, but you want it in that one time because any delays are costly and stressful.
Ashley Poulos: As a consultant, what are you able to do during this phase of the inspection?
Toya Brown: Typically when I'm called in at the failure point, it can be a little more hectic for the administrator or the leaders there at the center. A consultant can add so much value in the sense that we can work on a short-term or long-term basis and we're really flexible to the organization's needs. Having a consultant is having an expert on the team who can answer questions. I do weekly or monthly calls with some teams to talk strategy or just answer questions. I could assist with duties of opening new centers or changes of ownership, assist with survey prep, plan of corrections, policies, mock surveys, or even support on the days of the survey.
Another thing I help out leaders with is training staff for key roles like infection preventionist, quality manager, life safety, etc. When you're coming into these roles, it can be a bit overwhelming and the standards add more stress to your role as it is, so I come in and help to train them on what the expectation is, what to get done, and how to prioritize it all.
Ashley Poulos: What can the staff and leadership expect when you come on board?
Toya Brown: I basically support the business in whatever is needed. I ask them what's going on, and where they see me needed the most, and I just jump in and help out.
Ashley Poulos: Is there a financial benefit to having a consultant?
Toya Brown: Yes, I think so. I think with consultants it's typically temporary and you don't have to pay a year's salary, PTO, or vacations, so there’s an added value there. And we’re experts, there’s no need to train us, we’ve got our knowledge and are ready to help from the get-go.
Ashley Poulos: Do you personally work with a facility on a shorter basis or is it usually long-term?
Toya Brown: I do have some short-term clients and then I have one long-term client. It's really up to the center because my goal is to add value, I want to help. If it's not adding value to have a consultant then don't have one. If you've already been through this and you're very knowledgeable about it, then by all means bypass a consultant. But if you're new or just have some questions, there’s no harm in having that extra knowledge on your team.
Ashley Poulos: Have you found that if you worked with the center during the inspection, would they hire you when it came time for the next inspection? Like maybe have a downtime window and then you come back on board and help out later?
Toya Brown: Correct, yes. Or I go in a few times a year and just assess their quality. Sterile processing is it right now, I've been in a lot of sterile processing departments, ensuring that they are trained well and that their processes are on point, as well as their instrumentation. Clean instruments are a must for the business, for patients, and for us all.
Ashley Poulos: Say we passed our inspection and everything went well. What are some of your final thoughts or words of wisdom that you have for us as far as continuing the growth and improvement of our centers?
Toya Brown: Do your best to be survey-ready as much as possible because surveys are unannounced and CMS can show up whenever. So do your best to be survey-ready at all times and train your leaders on what to do if a surveyor walks in and the administrator or the DON is not present. Make them feel confident and strong in how to carry on or start the survey until the leaders can get there.
I also have some tips for physicians or owners of surgery centers. Allow time for survey prep, quality meetings, infection control, audits, and education. It truly adds value to your team. Address all medical staff that fail to follow the rules. Give your leadership team whatever they need to be successful. Overwhelmed leaders don't do well in surveys and it can be costly.
Lastly, your ASC or OBS has different standards than your clinic. Some of the things and practices you do at your clinic, you may not be able to do at your ASC, and that all is based on your standards.
Also, once the survey is passed, allow vacation time for your leaders because they truly deserve it.