Next up is Jim Collins to discuss preparing for a successful endoscopy unit accreditation survey. Jim, the floor is yours. All right. Thank you very much. All right. Gave our disclosure. So, overview. We're going to define licensure, certification, and the accreditation, we're going to list some behaviors to maintain survey readiness, and then describe expectations of what you can expect during a survey. So what do you think of when you hear of an AEC or a hospital? Do you think of the brick and mortar and the physical building itself? Do you think of your endoscopy unit? And what do you think of when you hear it's survey time? Do you think of individuals walking around with clipboards asking you questions or the hours of documentation that you are preparing for them to examine? Or do you think of people poking up ceiling tiles, looking to make sure that everything is sealed up to fire code? So licensure. Hospitals and ASCs, AECs must obtain a state license to operate legally within the state. Requirements, however, may vary from locality. But occasionally there are local permits that need to be attained as well. And this generally requires an onsite survey by the State Department of Health. When we look at certification, certification is the process which health care entities are approved for participation in federal payment programs such as Medicaid and Medicare. They're required by CMS for all sorts of health care facilities, be it a hospital, a nursing home, an AEC, and ASC. Must be obtained to ensure providers meet the applicable requirements of participation in the Medicare Medicaid program and are able to bill for them, as well as to be certified facilities must meet all the conditions for participation, also known as the COPs. Whereas accreditation is a volunteer process through which an organization is able to compare the quality of its services and operations against nationally recognized standards. So it's a measuring stick of your facility towards these national standards. There are a number of organizations which have earned deemed status from CMS. One of them is AAAHC. Another is the Association of Surgical Facilities. A newcomer on the block since 2008 or so has been DNV GL Healthcare, which is a Norwegian company that has deemed status for only hospitals to earn accreditation worthiness. And what's interesting with this organization is that it does annual accreditation surveys, not tri-annual like the others that have been mentioned. And lastly, there's the Joint Commission, which I think everyone is more highly familiar with and hear about quite frequently. Now accreditation requires a written application and a fee remittance prior to engaging of their onsite survey. It seeks to ensure patient safety and efficient operation, and again is used as that benchmark against national standards. Surveyors when they arrive will do a complete review of the physical facilities. They will observe patient care. They'll review the organization's physical plant, review all policies and procedures. They'll look at charts, personnel files and records, and often speak with clinical and non-clinical personnel during their survey. So why seek accreditation? Accreditation creates a distinction amongst competitors. There are also now certifications within accreditation approval for disease-specific care, which helps create further distinction amongst the competitors. It's essential to many contracts from third party payers. Again is the mark of quality for patient safety, and as we learned in the presentations today, consumerism of medicine is quite prevalent, and patients are shopping and comparing health care facilities. And finally, it drives continuous improvement within the facility itself, so you're constantly growing and improving. Survey compliance and endoscopy. To maintain survey readiness, there's a number of things that we may do to maintain accreditation readiness. It's everyone's responsibility to participate in accreditation readiness. As leaders, we can review past surveys and identify the gaps which are identified to fill them to ensure that the survey goes smoothly. We wish to stay current with standards, and we may do so through online blogs as well as online references from the accreditation agency. We wish to keep meticulous records of inspection and maintenance and repairs of all equipments and devices that we have on hand, be it our endoscopes, our reprocessing units, our storage cabinets, our vital sign monitors. We want to ensure that we have accurate records that can be easily retrieved and presented to surveyors should they ask. Also want to make sure that we document our QI, PI projects, such as our adenoma detection rates and withdrawal times that are recorded on our colonoscopy scorecards. We also may have PrEP quality studies that were done, studies for no-show rates, first attempt IV starts, a plethora of projects that can be done. Keep credentialing licenses current and readily available, and also with Joint Commission's new national patient safety standards, ensure that protection of patients at risk, namely patients at risk for suicide. Survey readiness in general, unit rounding and observation to prevent the discovery of low-hanging fruit is critical to prevent citation from being issued. So look for expiration dates of your supplies and drugs. Ensure that universal protocol is being performed. There's verbal agreement from each team member, and that the staff know, the caregivers know that they're able to stop and repeat the universal protocol if not complete. We've talked much about PPE, and surveyors will look that PPE is worn appropriately. They'll ask for hand hygiene audits that have been completed, and they'll also observe during their survey for hand hygiene practices. Show them the PI projects you have completed, and showcase them for the surveyors. This will also use up some time during their survey, so they're a little distracted and don't have too much other things to look at. And also have your contracted service performance evaluations ready for their inspection, be it this contracted caregivers that you may utilize, or ITD resources, laundry services. Ensure that those contracted service performance evaluations are readily available to show to the surveyors. Survey readiness rounding is essential to ensure that you remain survey ready, and are a great tool, again, to help maintain readiness. That includes general environmental rounding. You're looking at life safety concerns, your high-level disinfection and sterilization and storage practices. Review your own charts for thoroughness and completeness, and also make your own observations of timeouts are being done accurately and completely. Again, multidisciplinary team is utilized to facilitate your survey readiness. Pair up with your facilities people, your biomedical clinical engineering department, your infection control practitioners, your pharmacy staff, and also include all your staff in readiness rounding, and have them team up with these individuals as well to help discover and ensure that your unit is survey ready. Composing a readiness round checklist will greatly aid the staff as well as yourself to help prepare yourself for an upcoming inspection. They may be simple forms that indicate a standard to be met, and if it's being compliant or not, and also leave your space room so you're able to comment on the findings so you can correct them. They can be as little as a few questions, or as you can see, the small print, this is a 40-page survey form that may be utilized. We spoke a lot about the infection prevention standards of recent survey activity that have showed noncompliance with the infection control standards of O2, O2, O1, that 58% of hospitals and 60% of ASCs, and this was in 2019. Hospitals stayed the same in 2020, and ASCs fell two points in 2020 to 58%, so they're both lying at 58%, but what we found were policies and procedures not being followed, not adhering to the manufacturer's IFUs, facilities inability to validate the competency training of their staff, as well as the ability for the rank and file, the endoscope technicians to be competently oversight by an area manager, also lack of involvement of infection prevention in infection prevention activities, and again, what I shared with you, the leadership direction, lack of insight by the government body within these principles. So we want to make sure that it's quite an all-inclusive party. So what are some issues that aren't being readily identified is endoscope hang time is being identified by the accredited agency. They no longer are scoring solely on an arbitrary number of days. What they're looking for is that you do have a policy, and they look that you stick to your policy. They're looking for careful drying of endoscopes, so they're looking at the bottoms of cabinets to ensure there's no grippy drops on the floor of the cabinets, and they want to ensure that the instrument is protected from future contamination. We also want to focus on pre-cleaning of the endoscope, that the following manufacturer's IFUs are being followed as well, and the facility has a policy that governs the reprocessing of endoscopes. Also we want to make sure that there is documented time of pre-cleaning to manual cleaning due to the fact that two of the major endoscope manufacturers advise an hour from the time pre-cleaning is done to the institution of manual cleaning. A third gives direction that from pre-cleaning to manual cleaning is a continuous process and should be done uninterrupted. Also they look at transporting soiled endoscopes. It's no longer based on number of days. This is an error, and I forgive that, but they're looking to make sure that the endoscopes are transported in a fashion that prevents contamination of the environment from that scope being transported. Now there's a plethora of guidelines that a facility may follow of their endoscope reprocessing guidelines. We have from the CDC, the SG&A, and again you've heard of the 2021 Malta Society paper. Again I think the Malta Society paper stands out in its architecture of using the GRADE methodology to base its guidelines and recommendations for practice. We did speak a little bit of culturing of endoscopes. There were questions, and in 2018 the FDA, the CDC, and the Society of Microbiology devised a microbiological testing guidelines. It is a very tedious policy to follow, requires two individuals to be able to pull off the testing appropriately. So I just listed these as references for you. Survey readiness, we want to continue on to ensure that QA process for your test strips to measure MEC is followed per the MIFU. They need to be properly dated for an open time. The expiration date of that strip after it's been open. Be very careful when you date the container to ensure that months that have 31 days are included in the count so they are labeled appropriately. I give an example that something may be open on 6-29-21 and it doesn't expire on 9-29-21, it expires on 9-27 due to the 31 days experienced in July and August. Also make sure that the staff can appropriately describe the QA process of testing those test strips and have the ability to properly document the testing that has been completed. Okay, we did mention delayed reprocessing of endoscopes and surveyors will look to see that scopes are processed in a timely fashion. They're going to observe the pre-cleaning of endoscopes as well. So make sure that when the endoscopes are pre-cleaned, somewhere in the transport container that that time is documented, so we can ensure that the manual cleaning is instituted within that hour timeframe. Survey readiness will includes the proper transportation of that contaminated endoscope. We want to make sure that it's in a closed label transport container with the appropriate biohazard label, puncture resistance containers, only if you have accessories that will break the barrier of the transport container. We want to make sure that they're leak proof. Endoscopes are transported alone by themselves, coiled in a nice large loop. We don't put accessories in with the endoscope and these mandates are governed by OSHA, which requires the containers to be appropriately labeled as well. We don't want to use pillowcases or to transport the endoscopes as well, due to them not offering protectiveness for the endoscope or being very good barriers to maintain any potentially infectious materials. Survey readiness, we will go on. It's okay for the staff to use references to have such items readily available, are great tools for the staff, such as this pre-cleaning guide. It will ensure consistent practices. You may post these at the point of use and these visual instructions are good references for a prompt response by your staff when they're required to bond the pre-cleaning procedure by a surveyor. Okay, staff be able to follow their policies and procedure and that your institution is up to date with the IFUs. The surveyor will observe the staff working they're going to look for a flow from dirty to clean within the reprocessing area. They want to ensure that there's no back navigation from a clean area to a dirty area for potential of cross-contamination. Again, they will look for the pre-cleaning that is done correctly and also if delayed reprocessing protocols have to be instituted. They're going to look over all of your reprocessing logs. They're going to make sure that filters logs are changed appropriately in both your scope cabinets and your endoscope reprocessors. Again, they're going to monitor the MEC strips to ensure that they are changed appropriately as well as the time disposal of your high-level disinfectants. And also that your equipment is properly tagged for the appropriate PM that needs to be performed. So a gap analysis is done through your rounding to help you analyze any current processes versus the manufacturer's instructions for use to ensure that you are doing as instructed by the manufacturer. They will help identify any deficiencies that are in your practice and differ from best practices from either the MIFU or the guidelines. Also will determine sufficient resources within your facility exists to comply with all the manufacturer's recommendations and also help you determine the best resources that are needed to help you comply with the MIFUs. And also seek the input from your staff when doing your assessments to ensure that all the information is complete and is obtained and also will help determine which areas of the process need to be improved. The addition of flushing pumps may help with the manual cleaning of endoscopes, providing newer drying cabinets may help with facilitation of drying endoscopes for storage. And this is a form by HICPAC from the CDC is a sample of a gap analysis form or risk assessment that may be done to help ensure compliance. So survey readiness, the environment of care is the surveyors are going to really look at your institution with a fine tooth comb. They're gonna look up at the ceiling to ensure that there's no leaky substances that are dripping upon your ceiling tiles. They're going to ensure that items aren't stacked on top of cabinets that could interfere with the activation of a fire suppression devices. So take pictures and share your findings with your staff to hold everyone accountable for the activity within your department. Place work orders as necessary to help correct these deficits, remove any clutter. The joint commission especially is looking at egress. They're looking to ensure that gas shutoffs, that fire alarms, fire extinguishers are not blocked in any ways. So ensure that you remove clutter from the hallway, that items in the hallway are only stored on one side of the hallway. An easy one as well as to make sure that food and drink are eliminated from your procedural areas, your patient care areas. And this includes open up the drawers to ensure there's no coffee stains in there because they'll see a stain and they'll ask you, do you have a problem with people drinking in the room? Okay, and also look at your log sheets to ensure the PMs are done as well as temperature and humidity and pressure checks are done accordingly. Okay, survey readiness also entails life safety. So again, make sure that those fire alarms, the fire extinguishers are clear and free and obstruction free. Don't put plants in front of them or storage carts and also make sure that all your fire doors are kept closed and make sure all doors that are to be closed are closed and not propped open. So for survey readiness, you're going to look at your medical records. Consent need to be complete, dated time with appropriate signatures. They're going to review H and P's to ensure that they're documented completely in all fields. And they're going to look if care plans are complete, including the timeframes, which that plan is expected to be executed and complete. Looking for documentation if interpreters services are required and that if you, for patients who English is not their preferred language. And again, safe medication practices, the safe injection practices, looking to make sure that all medications are labeled appropriately and your narcotics are reconciled appropriately. Continuing on survey readiness, personnel considerations are to ensure that your credentialing and privileges of your physicians are accurate and complete. They will ask staff to go through the mechanism of validation if the provider they're working with is properly credentialed to do the procedure. They may also ask if you have certified staff, nurses which are certified, you're reprocessing techs. This is also a great opportunity for you to share that these employees are because it shows a great commitment towards patient safety efficiency, as well as promoting a very smooth operation. They'll look at employee files for orientation documentation. And a new thing with documentation, especially criteria and checklists, they want to see that every box is checked in initial. They're getting a little bit prudish now on the one check and one initial with a line going down to the bottom. They like to see every box complete now. And document continuing education that's held within the unit. And again, our vendors can be great resources at providing education to our employees. Document the competencies, these criteria and checklists as well. Who performed the competency review is imperative. So they may review how the individual who is your train the trainer became competent to do so. And one mechanism is to attend train the trainer courses that are available or through documented education skill verification through other courses. They're going to ensure that there are return demonstrations that are done with the competency assessments. And of course, with the facility taking on new procedures and equipment that staff are adequately trained on these devices. When survey day comes around, you want to ensure that you're ready to do so. And by printing out a simple checklist for staff to follow when the surveyors arrive, it helps put your plan into action. So each of the accreditation agencies will trace a patient through the facility from the time they're registered to discharge. They will observe at least one procedure from beginning to end and also observe an endoscope being reprocessed. If it's a CMS visit, then CMS inspectors are also obliged to observe a duodenoscope being reprocessed if your facility does so. Also random charts will be opened and observed for completeness and employees files will be reviewed. All staff will be interviewed during the survey from your clinical techs to reprocessing techs to nurses, also your physicians. And if you have been engaged in a virtual survey, they're quite fascinating because the eye of the camera sees a lot and they're sometimes not paying attention to your speaking but looking at the background picture and asking what that individual is doing back there and asked to talk with them. So surveys have definitely evolved. Do your quick environmental sweep, drain the department of food and drinks only in the appropriate spots and hydration station. Ensure that there's egress to your gas shutoff valves and fire extreme nourishers aren't blocked. Make sure that your O2 tanks, you have the appropriate number permissible for your unit, that they're stored correctly. Outside corrugated cardboard shipping boxes have been removed and products have been removed from any cardboard boxes that are outside shipping containers have been removed. Ensure that protected confidential information has been discarded appropriately into a shredding bin that's not tossed into the regular garbage, that computer screens aren't left on where patient information may be accessed. And again, looking at that storage space, 18 inches from the ceiling or from the sprinkler head. And they're also gonna look at your storage racks, especially the bottom rack to make sure that there is a barrier on that bottom rack. So there's no potential contamination from environmental services doing their cleaning. And also just do a quick cleanup of the department to ensure that it is decluttered. So dependent on the size of your facility, ensure that you have one of your staff member available to assist each surveyor, prepare the workspace for your surveyor to work so they can examine papers. They may ask for a wifi connection as well. So they may have a secure line to check with their home offices. If it is possible, correct any deficiencies or problems on the spot that shows very straightforward and forward thinking during your survey. Answer all questions honestly, but only answer the question directly. Don't elaborate. Also try to instill upon your staff member that when they answer questions, especially regarding policies and procedures to say, this is the fashion not to say, oh, this is how I do it because then they're gonna ask a lot of people how they do it. And make sure your staff know your PI and QI projects so they can share and celebrate with those. So in summary, preparation is critical. If you can't wait three years to prepare for a survey, it's an ongoing process. So get ready and stay ready. Infection prevention should be a way of doing your business every day, not just when you expect surveyors to come knocking at the door. Involve everyone in your team to prepare because the first people they see is going to be your front desk personnel, your reception and lobby staff. So they need to be prepared as well. Perform your own mock surveys and your tracers to help you prepare. And again, encourage the partners in your facility to help you as well to prepare for the exam to identify deficiencies. So in summary, celebrate your success when you do get ready and you are ready. So it may be a very uneventful event for you. And that's what I have for you today.

endoscopy unit accreditation survey

licensure

certification

accreditation

healthcare entities

deemed status

patient safety