quality in the GI unit. And the talks are really going to emphasize that. And we're going to start with Jim Collins, who's really sort of just a vast array of knowledge on stuff that most of us don't know enough about. As you already heard from his first talk, now you're going to hear more about how to prepare for a successful DOSP unit accreditation survey. And this is one of those ones you're going to take notes and then probably watch again before it happens. Thanks again, Jim, for enlightening us. Oh, thank you so much. It's a great privilege to be with you again. Like I say, I always learn so much from these courses as well. So we don't have to do the disclosure. We stated that already. So overview, we're going to look at licensure, certification, and accreditation. We'll list several behaviors to maintain survey readiness. And then we'll describe expectations of what you may expect during your survey. So what do you think of when you hear of AEC or hospital? Do you think of all the brick and mortar of the building, the glass, the rooms? Do you think of the equipment you will utilize throughout the day? Do you think of the patients that you will care for? Do you think of your coworkers? Then what do you think of when you hear it's survey time? Do you imagine strangers walking about your unit asking questions and taking notes? Do you relish preparing all the documents, charts, SOPs that will be reviewed by the surveyor? Do you envision people carrying around ladders, popping ceiling tiles, and looking into the space above the ceiling tiles for imperfections? Well, when it comes to accreditation, accreditation is all of that. Accreditation is providing the best and safest care to our patients in the safest environment with the safest practices and equipment. So let's look at licensure. Licensure, hospitals, and ASEs, AECs must have state licenses to operate legally. Requirements may vary by law and generally require an on-site survey. So again, you pay the state for a license so you may open up your business. Certification may be done by the state as well who represents CMS. And this is the process which health care entities are approved for participating in federal payment programs such as Medicare. It's required by all facilities who wish to receive monies from CMS. It must be obtained to ensure providers meet the applicable requirements for participation in the Medicare Medicaid program and therefore be able to bill for their services. And to be certified, facilities must meet the basic conditions for participations from CMS. And these only number 3,000 COPs. And then what is accreditation? Accreditation is a voluntary process through which an organization is able to compare the quality of its services and operations against nationally recognized standards. There are several accreditation agencies that a facility may choose. There's AAAHC. There's the Association of Ambulatory Surgery Facilities. Newer accreditation agency is DNVGL Healthcare. There's also probably the most known is the Joint Commission. And there's about a half dozen other organizations as well that serve as accreditation agencies for CMS and can provide deemed status. So accreditation requires a written application prior to the on-site survey. So you have to fill out the contract, fill out the application, send in the payment for the accreditation agency to be placed on their schedule to come survey you. It seeks to ensure patient safety and efficient operations. And surveyors will visit your facility and observe patient care, review the hospital's physical facilities. They'll research all the policies and procedures. They'll look through EMR and charts. They'll look at personnel files and training records. And we'll also speak with clinical, non-clinical personnel on various topics, such how they were trained and oriented. And lastly, they'll also speak with patients on how their care was presented to them. So why seek accreditation? Well, accreditation will provide a competitive advantage amongst competitors in the area. It proves assurance the organization is current with health care regulations, improved customer satisfaction ratings, and also studies have shown that these centers also operate more efficiently. Accreditation is required for deemed status from CMS to receive payment and also may be required by the plethora of other third-party payers if you wish to have their patients seek their care at your facilities. Accreditation demonstrates commitment to excellence in quality, accountability, and patient safety. It also improves risk management and risk reduction. Accreditation will also provide opportunities for ongoing education and training for your staff and provide standardization and consistency for processes across the organization, as well as support continuous quality improvement efforts within your facility. So accreditation serves a plethora of services to the health care facility. So survey compliance and endoscopy. Let's take a look. So first and foremost, maintaining survey readiness is the function of each and every individual, not just the center administrator or the director of accreditation. It's all of our responsibility. But how can we help is we need to review our past surveys and identify the gaps that were noted during those surveys. We need to stay current with the present standards from the accreditation organization. We need to keep meticulous records and inspections of all our maintenance repairs of all our equipment and devices. We want to ensure that we document all our QI and PI projects that have been performed within the facility as well. And to be able to have these projects at hand and ready to present can occupy a great deal of the surveyor's time. So show off the good works that you do within your organization, because an accreditation survey is really your World Series, your Super Bowl, your Daytona 500. It's your chance to sparkle. So keep credentialing and license of files current of your staff. And also, we must not forget our behavior patients and ensure protection of those patients who are at risk for suicide. So survey readiness in general. We want to do a good inspection and thorough look through of our institution, our facility. We want to check expiration dates of all our equipment, of all our supplies, our pharmaceutical goods. We want to ensure that everyone is on tune with the practice of universal protocol. Surveyors would look to ensure that there's verbal agreement from the team on the patient, the procedure to be performed. And they're also looking to ensure that all staff participate with the practice of the universal protocol and that each staff feels comfortable to stop and repeat the practice if they do not believe that it's in sync with what's to be done. We spoke about PPE. They'll observe that PPE is worn accordingly, that gowns are tied, that masks are up and covered, what needs to be covered, that eye protection is being worn. They will look at the hygiene practices within the facilities as well. Again, showcase your PI projects that you have performed. Also, they're quite interested in the contracted services and your evaluation of the performance of these contracted services. Many of them may deal with regulated waste handling, pharmacy issues such as reconciliation of narcotics, as well as how are wasted medications disposed of. Survey readiness is based upon rounding. Get out and observed what's happening within your unit. And there's various areas that we look at when we round. You're looking at the environment, life safety features of the unit, high-level disinfection practices, chart review for thoroughness, and general observations of patient flow and of patient satisfaction within the unit as well. So conduct and place together a multidisciplinary team made up of various individuals and departments, your facilities company, bioclinical engineering, infection control practitioners, pharmacy, your medical staff, and administrative staff as well. All come together to round and to trace and to observe the functions and the practice within the facility to help improve the practice. So how are you going to do this is that you're going to formulate a rounding checklist. And checklists are available from all the various accreditation agencies that you may build from the templates and design specifically for your facility to help you guide the practice. This just looks, this log looks at high-level disinfection and sterilization practices. But you can customize these templates to look at logs for checking your emergency equipment, for checking refrigerators within the department as well, to look at logs that monitor temperature and humidity. So there are various templates that may be utilized to help you in the rounding process that readily will identify any deficiencies that you have within the unit. You want to identify these deficiencies first, these low-hanging fruits, and harvest them before a surveyor has the opportunity to pluck them from the tree. And they end up as findings on your accreditation survey. So I spoke a lot of Joint Commission for, that's the accreditation agency I know the most of. But infection prevention principles are solid throughout these accreditation organizations. They will look to ensure that there is a plan of infection prevention and a control plan accordingly. They'll look to see that there's a reduced risk of infection with the reprocessing of your devices that you utilize within the unit. And I shared with you that there is a high rate of noncompliance and deficiencies that have been observed throughout the health care industry. And what are these findings? Usually not following your own policy and procedures, not adhering to the manufacturer's instructions for use, lack of validation of competency of staff, also lack of competent oversight of the individuals, lack of involvement of infection prevention in the creation and monitoring of your infection prevention plan, and lack of oversight by the governing body. There are many guidelines for a facility to choose to govern their practice. The CDC has their own guidelines towards the essential elements of endoscope reprocessing. SG&A has standards as well. ASGE, the Multisociety Guideline for Reprocessing Endoscopes came out in 2021. ARN just updated their standard, and that's now available from them. So that's really a revision of 2022. And we know that AIME ST91, dealing with flexible endoscope reprocessing, also was released in March of this year. And also for those that do have duodenoscopes in their practice, in 2018, the FDA, CDC, as well as American Society for Microbiology developed a duodenoscope surveillance and culturing protocol. Now, survey readiness is based upon your rounding and identifying gaps and closing those identified gaps. And one of the prevalent findings have been quality control checks for new test strips used during high-level disinfection to ensure that they are labeled according to the date they're open, they're expired, and maintaining a QC log if noted. So if you look at this jar of test strips, we can see that it is dated. Some has washed off. But unfortunately, when we look at the expiration date, they gave us an extra date to use the strips. So use Siri, use your phone to easily identify when the test strips will expire, a real frequent finding during survey. Another key area that all accreditation agencies are focusing in on is our delayed reprocessing of endoscopes. So, does the unit have a policy that directs the identification of when point of use treatment or that bedside pre-cleaning is performed and when it is clearly marked on the transport container so the staff within the reprocessing room will identify and prioritize the endoscopes would need to be processed before that 60-minute period has expired. Looking at survey readiness, they will observe the transportation of endoscopes. They'll look that they are transported in closed, biohazardous-labeled containers that are puncture-resistant. They'll look at that they're leak-proof so that there is not any chance for potentially contaminated waste escaping the transport device. We want to ensure that separate containers are utilized for any reusable GI accessories. And this is a practice that's governed by OSHA. So, there are various devices on the market that may be utilized for endoscope reprocessing transportation. Survey readiness, standardization of work instructions, is they're looking for what type of devices do you have for your staff, work aids, job aids, cheat sheets, per se, that will help identify the tasks to be done and will guide the caregiver in performing those tasks. So, it's okay for staff to reference these devices, to have them readily available. It ensures consistent practice. This one is for point-of-use care, and it serves as great visual instruction for the caregiver if a surveyor would ask them of the task of point-of-use care. Survey readiness in key areas that need to be addressed, the staff need to speak and follow the policies and procedures of the facility and provide up-to-date IFUs. So, there are facilities that utilize electronic means for policies and procedures and MIFUs. Other have paper copies. If you utilize paper copies, ensure that the latest update of those documents are on hand. They will observe the staff to ensure that there is dirty to clean flow within the reprocessing room, and they'll look to ensure that pre-cleaning is done and that there is a note towards delayed reprocessing of endoscope. They love to look back through logs to make sure that the filters of the AERs are changed in accordance to MIFU. And now, with the use of air circulators within storage cabinets, ensure that your storage cabinet filter is changed according to MIFU again. I already mentioned MEC testing, and they'll look for high-level disinfectant replacement as well. And they'll probably ask for logs for your AERs to ensure that they have preventative and planned maintenance performed as directed. Now, survey readiness, high-level disinfection gap analysis, is you want to look at your practice, your policies, and compare them to the manufacturer's recommendations for cleaning, processing, transporting, and storage of the endoscopes that you have in your inventory. When you identify deficiencies, you wish to look at your practice and how do they differ from the best practices of the manufacturer recommendations. Determine if sufficient resources exist within your facility to comply with all the manufacturer's recommendations, and then determine what additional resources are needed in order to comply with the manufacturer recommendations. So, this may mean updating your equipment, purchasing new equipment, purchase of proper storage and transportation containers, and also seek input from your staff who are performing these processes to ensure that the pertinent information is obtained and is accurate. And HCPAC has a nice tool available to you for performing a simple gap analysis tool related to endoscope reprocessing. You may find it simple to use and readily identifies any deficiencies. So again, survey readiness when it comes to the environment of care looks at the building and the structure itself, and appearance matters, right? You don't get that second chance at a first impression. So, take a good look around, share photos of your findings with your other caregivers, and bring the other caregivers along with you when you round so you can share the findings and hold peers accountable for their practices. Most findings during a survey are due to behavioral patterns of the caregivers and not related to specific duties. So, place work orders or contact contractors for any deficiencies that need to be corrected, remove that clutter, and food and drink from within the procedure areas. Again, make sure those log sheets are done, that the PMs on equipment is performed, and especially those humidity and pressure checks that need to be done within the reprocessing rooms. Survey readiness, when we look at life safety, we have to ensure that our fire alarms are unobstructed, also our fire extinguishers there's easy access to, and that we don't block egress from the department by blocking fire doors. Medical records, surveyors will look at consents to ensure that they are complete, that they're dated in time and have the appropriate signatures, that H&Ps are updated with all the required areas. Units that may utilize trainees, ensure that if your policy calls for co-signing by the attending, that this is done in a timely fashion, the timely fashion is before the procedure begins. Care plans need to be complete and include timeframes when the elements of these care plans are expected to be completed. Also, document interpreter use for patients who preferred language is not English and have all on hand know the procedure to procure interpreters if they are needed. Safe medication practices, again, surveyors may observe this by just simply standing back and looking. They're going to look for the safe injection practices, single use of syringes and needles, that medications are properly labeled and secured after they're drawn, and also medication reconciliation that is done in a timely fashion, especially when it comes to narcotics. When we look at personnel considerations, we wish to ensure that our physician privileges and their credentials are current. If we have staff that require certification, such as CRNAs that we have, that their advanced practice license is current and up to date as well. All staff within the house, we want to have their orientation documentation that it is current and up to date and their continuing education is documented. They'll look at the annual competencies that they're performed, who performed them and who performed the company's assessment of the person who does this testing as well. They'll look to see if it's purely didactic or if there are return demonstrations that are given and ensure that all individuals are trained accordingly to new procedures and equipment when they are made available within the unit. A new aspect of accreditation are accreditation agencies looking at diverse populations that healthcare facilities serve. So this has been readily identified and brought out through especially the COVID that shed light on gaps in healthcare that diverse populations have experienced for decades and now it's becoming an incremental part of the care which organizations are rendering and what organizations are doing to narrow the gap and promote the care to these patients. In matter of fact, the Joint Commission on the 28th of September just announced a new advanced certification program that institutions may apply for on improving health care equality and diversity. So part of the strategies are focused upon the leadership of the facility to use social intervention to help identify the needs of the patient populations to collaborate with community leaderships in this strategic plan for community outreach programs and support to these individuals and also support for the local workforce as well in being able to service these communities. Then when survey day does come and remember that surveys are unannounced and you're given a time frame when they may come but most of the time it's a knock on the door at at 730 to say here we are we're here to inspect your unit. So accreditation agencies will trace a patient from their registration to discharge. Surveyors are obliged to observe at least one procedure being performed within the unit. They are to observe endoscope reprocessing in its entirety. So that includes the point of use care through stowing the scope in the cabinet. They will randomly look through patient charts. They are to look at 10% of the volume of a day. So depending on the activity of your unit then depends upon how many charts will be reviewed and then they may select an employee file to be reviewed usually one from each category of caregiver that you have. They will also speak with your medical staff and they will speak with your patient access individuals as well your admins to to investigate how care is delivered and more importantly they will speak with patients to on how they felt their care was delivered to them. So on this survey day do your environmental sweep of your unit. Make sure there are no food or drinks within the unit. This is an OSHA mandate as I shared with environmental care and life safety. Make sure egress is is not hindered that there are no items blocking gas shutoff valves fire extinguishers or pull stations check your oxygen tanks for the appropriate numbers and storage. Make sure that these are labeled accordingly to empty or full and they are stored appropriately as well not commingled in a single rack. Outside shipping boxes these cardboard critters often hinder our supply rooms. So ensure that outside shipping boxes corrugated cardboard the products are removed and those boxes are placed in the trash always promote and protect confidential information don't have computer screens on that show access to patients information and also that any paper documentation is placed into a the appropriate disposal bin check storage and make sure that devices are not more than 18 inches from the ceiling or from sprinkled sprinkler heads and generally declutter your unit and when the surveyors come most units are rather will have just one if you're an AEC will have one or two surveyors come so have one staff member available to each surveyor. We just went through a survey and we had 16 surveyors who came to visit us. So we did a lot of traveling prepare space for the surveyors to perform their work. This may be computer availability for them as well and Wi-Fi connection in case they need to speak with their accrediting organization if possible correct any deficiencies that are noted on the spot instruct your staff to answer all questions honestly, but only answer the questions that have been asked and don't elaborate again know your PI projects and QI projects because these will showcase and master put into a marquee the good work that you're doing additional practice pearls are preparation is critical. You don't prepare for a survey you prepare for the next patient. So accreditation readiness is an ongoing process perform your mock surveys your tracers year-round to keep in tune to the accreditation standards involve all clinical and administrative and support staff in these roundings to assure that they appreciate all the work that's ongoing and have your partners in health care around with you IP professionals pharmacy medical records clinical engineering your facilities people as well. All individuals play a hand in a successful accreditation survey. And that's what I have for you this afternoon. I thank you for your attention.

accreditation

healthcare facilities

survey readiness

patient care

regulatory compliance

deemed status

continuous improvement