Improving Quality and Safety in the Endoscopy Unit (On-Demand) | August 2023-10_ASGE Quality_Collins

10_ASGE Quality_Collins_Accreditation

Pdf Summary

The document provides guidance on how to be prepared and successful for an Endoscopy Unit Survey Accreditation. It starts by defining licensure, certification, and accreditation, with licensure being the state license required for operation and certification being the approval for participation in federal payment programs. Accreditation is a voluntary process that compares the quality of services and operations against recognized standards.<br /><br />The document emphasizes the importance of maintaining survey readiness through behaviors such as reviewing past surveys, rounding on the unit, staying current with standards, and keeping meticulous records of equipment inspections and maintenance. It also highlights the need for audits, tracers, and rounding, as well as collaboration with multidisciplinary teams.<br /><br />Specific areas of focus for survey readiness in endoscopy include infection prevention, adherence to guidelines and standards, proper equipment handling and storage, and maintaining accurate records. The document also discusses the importance of addressing gaps identified during surveys, implementing standardized work instructions, and ensuring compliance with regulations related to staff competence and patient safety.<br /><br />It provides information on key areas for survey readiness in healthcare facilities, including the environment of care, life safety, medical records, medication practices, personnel considerations, and the needs of diverse populations. It emphasizes the importance of equity, strategic planning, and community outreach.<br /><br />During the survey day, accrediting agencies will trace patient care from registration to discharge, observe procedures and endoscope reprocessing, review patient charts and employee files, and interview staff and patients. It advises on preparing the facility, answering questions honestly, and having partners from infection prevention, pharmacy, and medical records visit in advance.<br /><br />The document concludes with practice pearls, including a set of questions to test understanding. It emphasizes the importance of maintaining survey readiness at all times, performing mock surveys in advance, and involving all staff in the process. It also highlights the options available to hospitals for CMS certification or accreditation.<br /><br />Overall, the document provides a comprehensive guide for healthcare facilities to be prepared and successful in obtaining endoscopy unit survey accreditation.

Keywords

Endoscopy Unit Survey Accreditation

licensure

certification

accreditation

survey readiness

standards

equipment inspections

infection prevention

patient safety

healthcare facilities