Improving Quality and Safety In Your Endoscopy Unit (Virtual) | October 2021-Preparing for a Successful Endoscopy Unit Survey Accreditation

Video Transcription

Video Summary

In this video, Jim Collins discusses preparing for a successful endoscopy unit accreditation survey. He begins by defining licensure, certification, and accreditation and explains that hospitals and ASCs must obtain a state license to operate legally. Certification is the process by which healthcare entities are approved for participation in federal payment programs such as Medicaid and Medicare. Accreditation is a voluntary process that allows organizations to compare the quality of their services and operations against nationally recognized standards.<br /><br />Collins then discusses various organizations that have earned deemed status from CMS, including AAAHC, the Association of Surgical Facilities, DNV GL Healthcare, and the Joint Commission. He explains that accreditation requires a written application and fee remittance, and surveyors will review the physical facilities, observe patient care, and review policies and procedures.<br /><br />The speaker emphasizes the importance of seeking accreditation, as it creates a distinction among competitors, is essential for contracts from third-party payers, and serves as a mark of quality for patient safety. He also explains that survey readiness involves maintaining meticulous records, documenting quality improvement and patient safety projects, keeping credentials and licenses current, and ensuring protection of patients at risk.<br /><br />Collins discusses various aspects of survey readiness, including maintaining accurate records of equipment maintenance, ensuring compliance with infection control standards, and conducting roundings to prevent citations. He also emphasizes the importance of proper endoscope reprocessing, transportation, and hang time.<br /><br />The speaker provides recommendations for survey readiness, such as keeping up with standards through online resources, involving staff in accreditation readiness, and conducting gap analyses to identify areas for improvement. He also highlights the importance of environmental and life safety considerations, proper documentation, and personnel considerations.<br /><br />In summary, Collins emphasizes the importance of ongoing preparation and involvement of the entire team to ensure survey readiness. He suggests performing mock surveys and tracers, involving partners in the facility, and celebrating success in achieving readiness.

Asset Subtitle

James Collins, RN, CNOR

Keywords

endoscopy unit accreditation survey

licensure

certification

accreditation

healthcare entities

deemed status

patient safety