Improving Quality and Safety In Your Endoscopy Unit: Live and Virtual

11_Collins_Accreditation
Pdf Summary
In this document, James Collins, an accreditation professional at the Cleveland Clinic, provides information on how to be prepared and successful for an endoscopy unit survey accreditation. He defines licensure, certification, and accreditation and lists behaviors to maintain survey readiness. Licensure refers to the state license required for hospitals and ambulatory surgery centers to operate legally, while certification is the approval for participation in federal payment programs like Medicare. Accreditation is a voluntary process that compares the quality of services and operations against national standards.<br /><br />Collins highlights the importance of seeking accreditation, as it is essential for many contracts, serves as a mark of quality and safety for patients, drives continuous improvement, and creates distinction among competitors. He emphasizes the need to maintain survey readiness by involving everyone in the process, reviewing past surveys to identify gaps, staying current with standards, and keeping meticulous records of equipment maintenance and repairs.<br /><br />The document also provides information on specific areas of survey readiness, such as expiration dates, the universal protocol, personal protective equipment, hand hygiene, and performance evaluation of contracted services. It discusses the importance of audits, tracers, and rounding for environment, life safety, high-level disinfection, and chart review. It suggests pairing up with facilities, biomedical, infection control, and pharmacy departments to ensure a multidisciplinary approach.<br /><br />Collins emphasizes the need for compliance in infection prevention and control, particularly with reprocessing flexible endoscopes. He references guidelines from organizations like the CDC and AAMI to ensure proper reprocessing practices are followed. He also mentions key areas such as reprocessing delays, transportation, standardized work instructions, staff adherence to policies and procedures, and equipment maintenance.<br /><br />The document concludes with information on survey day, where accrediting agencies will observe patient care, endoscope reprocessing, and review patient charts and employee files. Collins advises staff to answer questions honestly and efficiently, know their quality improvement projects, and involve all clinical, administrative, and support staff in maintaining survey readiness.<br /><br />Overall, the document provides a comprehensive overview of how to be prepared and successful for endoscopy unit survey accreditation, addressing key areas of focus and emphasizing the importance of maintaining survey readiness at all times.
Keywords
accreditation
endoscopy unit
survey accreditation
licensure
certification
national standards
survey readiness
continuous improvement
patient safety
reprocessing practices