David C. Watts, MD, the Vice President of Education for the American Association for Accreditation of Ambulatory Surgery Facilities(AAAASF), discusses five mistakes to avoid when pursuing Medicare accreditation in an ambulatory surgery center.
"The process requires incredible vigilance to make sure that everything gets done, but once you have it and you do it, you will have an incredibly safe facility," says Dr. Watts, who also serves as a plastic surgeon at Plastic & Cosmetic Surgery Institute in Vineland, N.J.
Here are some of the mistakes he sees in the Medicare accreditation process:
1. Not complying with federal and state standards. In addition to the federal standards for Medicare accreditation, each of the nine designated regions in the country can interpret the standards differently, says Dr. Watts. "The state can send in Medicare inspectors in addition to your deeming authority on the federal level, and how they interpret the standards may be different," he says. It is therefore important to research the state-specific standards for accreditation prior to the inspection.
For example, the standards for the amount of dantrolene that must be stocked in an ambulatory surgery center differ at the state and federal levels. According to federal standards, the surgery center can have 12 vials in stock but must be able to obtain an additional 24 vials at a location within five minutes of the center, such as at a local hospital. However, according to the standards for region two, which encompasses part of the east coast, a surgery center is required to have all 36 vials stocked in its facility. In this case, the center must comply with whichever standard calls for the higher amount of stocked vials, says Dr. Watts.
"The majority of Medicare facilities don't know this [difference between federal and state standards] exists unless they have some sort of interaction with the state," he says. "But that's important because if you don't know about this ahead of time, there's no way you're going to pass a validation survey performed by State agency surveyors."
2. Unclear documentation for infection control. Infection control meetings address quality infection control topics such as sterilization techniques, hand washing, postoperative infections, protocols for needle sticks and cleaning processes. All clinical staff members must be in attendance and the meeting minutes should be documented, says Dr. Watts. "The meeting minutes have to chronicle exactly what was said and gone over. If there are any problems, you should document what the plan of action is and how you plan to correct it," he says.
3. No formal training in infection control. At least one nurse in the surgery center must have formal training in infection control, such as through a self-paced course offered by the Association of Perioperative Registered Nurses, says Dr. Watts. Without this training, surgery centers are in danger of not passing the inspection.
4. Lack of quality assurance program structure. One of the most common mistakes Dr. Watts has seen as an inspector is the lack of an adequate quality assurance program in surgical facilities. "You want to look at how you're logging in and tracking narcotics, handling disciplinary problems, the advanced directives looked at by patients, the bill of rights looked at by patients — this has to happen on a daily basis for every case," he says. "You want to make sure that documents like pathology reports and x-rays are being signed off on by the physician doing the case. All of this has to be checked."
5. No leader to spot small mistakes. To ensure that small mistakes do not get overlooked at the center, it can be helpful to assign one staff member — typically the supervising nurse — to the role of coordinating the Medicare accreditation process, says Dr. Watts. "It's an involved process, and you want to make sure that everything gets checked," he says. "You need someone to monitor outdated medication and make sure that staff credentials are all up to speed because they're constantly coming up at different times."
Creating a checklist to keep track of various deadlines, including credentialing dates and six-month biomedical equipment inspection requirements, can also be helpful, says Dr. Watts. It is also important to stay vigilant about administrative processes, such as keeping staff members' advanced cardiac life support cards (ACLS) and licenses on file, because a surgery center that lags in meeting these requirements may not achieve Medicare accreditation.
"In the day-to-day process of running a surgery center and taking care of patients, these requirements can get overlooked — but that is what will fail you," says Dr. Watts. "I've failed centers because their paperwork wasn't up to speed and because these deficiencies started adding up."
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"The process requires incredible vigilance to make sure that everything gets done, but once you have it and you do it, you will have an incredibly safe facility," says Dr. Watts, who also serves as a plastic surgeon at Plastic & Cosmetic Surgery Institute in Vineland, N.J.
Here are some of the mistakes he sees in the Medicare accreditation process:
1. Not complying with federal and state standards. In addition to the federal standards for Medicare accreditation, each of the nine designated regions in the country can interpret the standards differently, says Dr. Watts. "The state can send in Medicare inspectors in addition to your deeming authority on the federal level, and how they interpret the standards may be different," he says. It is therefore important to research the state-specific standards for accreditation prior to the inspection.
For example, the standards for the amount of dantrolene that must be stocked in an ambulatory surgery center differ at the state and federal levels. According to federal standards, the surgery center can have 12 vials in stock but must be able to obtain an additional 24 vials at a location within five minutes of the center, such as at a local hospital. However, according to the standards for region two, which encompasses part of the east coast, a surgery center is required to have all 36 vials stocked in its facility. In this case, the center must comply with whichever standard calls for the higher amount of stocked vials, says Dr. Watts.
"The majority of Medicare facilities don't know this [difference between federal and state standards] exists unless they have some sort of interaction with the state," he says. "But that's important because if you don't know about this ahead of time, there's no way you're going to pass a validation survey performed by State agency surveyors."
2. Unclear documentation for infection control. Infection control meetings address quality infection control topics such as sterilization techniques, hand washing, postoperative infections, protocols for needle sticks and cleaning processes. All clinical staff members must be in attendance and the meeting minutes should be documented, says Dr. Watts. "The meeting minutes have to chronicle exactly what was said and gone over. If there are any problems, you should document what the plan of action is and how you plan to correct it," he says.
3. No formal training in infection control. At least one nurse in the surgery center must have formal training in infection control, such as through a self-paced course offered by the Association of Perioperative Registered Nurses, says Dr. Watts. Without this training, surgery centers are in danger of not passing the inspection.
4. Lack of quality assurance program structure. One of the most common mistakes Dr. Watts has seen as an inspector is the lack of an adequate quality assurance program in surgical facilities. "You want to look at how you're logging in and tracking narcotics, handling disciplinary problems, the advanced directives looked at by patients, the bill of rights looked at by patients — this has to happen on a daily basis for every case," he says. "You want to make sure that documents like pathology reports and x-rays are being signed off on by the physician doing the case. All of this has to be checked."
5. No leader to spot small mistakes. To ensure that small mistakes do not get overlooked at the center, it can be helpful to assign one staff member — typically the supervising nurse — to the role of coordinating the Medicare accreditation process, says Dr. Watts. "It's an involved process, and you want to make sure that everything gets checked," he says. "You need someone to monitor outdated medication and make sure that staff credentials are all up to speed because they're constantly coming up at different times."
Creating a checklist to keep track of various deadlines, including credentialing dates and six-month biomedical equipment inspection requirements, can also be helpful, says Dr. Watts. It is also important to stay vigilant about administrative processes, such as keeping staff members' advanced cardiac life support cards (ACLS) and licenses on file, because a surgery center that lags in meeting these requirements may not achieve Medicare accreditation.
"In the day-to-day process of running a surgery center and taking care of patients, these requirements can get overlooked — but that is what will fail you," says Dr. Watts. "I've failed centers because their paperwork wasn't up to speed and because these deficiencies started adding up."
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