Improving Quality and Safety In Your Endoscopy Unit: On-Demand | October 2022 OLQUALOCT22-11_Collins

11_Collins_Accreditation

Pdf Summary

This document is a guide on how to be prepared and successful for endoscopy unit survey accreditation. It defines licensure, certification, and accreditation in the healthcare industry. Licensure is necessary for hospitals and ambulatory surgery centers to legally operate, while certification is required by CMS for all facilities participating in federal payment programs like Medicare. Accreditation is a voluntary process that allows organizations to compare their services and operations against nationally recognized standards.<br /><br />Accreditation is important for several reasons, including being essential for many contracts, serving as a mark of quality and safety for patients, driving continuous improvement, and creating a distinction among competition. The document highlights the importance of survey readiness, which involves maintaining accurate records, updating policies and procedures, and ensuring the protection of at-risk patients.<br /><br />To achieve survey readiness, the guide suggests involving all staff members in the accreditation readiness process, reviewing past surveys, staying current with standards, keeping meticulous records, and documenting quality improvement projects. It also emphasizes the need for adherence to infection prevention and control guidelines and proper reprocessing of endoscopes.<br /><br />Other key areas of survey readiness include maintaining a clean and organized environment, ensuring compliance with life safety regulations, properly documenting medical records and medication practices, and having qualified and competent staff through credentialing, orientation, education, and competency assessments.<br /><br />The document suggests strategies to understand the needs of diverse populations in the community and support community outreach. It also outlines what to expect on survey day, such as tracer activities, observations of endoscope reprocessing, and interviews with patients and staff. It emphasizes the importance of preparation, maintaining survey readiness at all times, and involving all key stakeholders in the process.<br /><br />Overall, this guide provides a comprehensive overview of how to prepare and succeed in an endoscopy unit survey accreditation.

Keywords

endoscopy unit survey accreditation

licensure

certification

accreditation

survey readiness

quality and safety

continuous improvement

infection prevention and control

endoscope reprocessing

community outreach