Okay, so you know my disclosures, so let's look at an overview of what I'll speak about today. We're going to find various mechanisms that are necessary to achieve accreditation and what do those mean, licensure, certification, and accreditation, and list behaviors to maintain survey readiness, and help describe expectations during a survey. So these two have their map and they're ready to navigate the pathway towards a successful accreditation survey. So what do you think of when you hear the word AEC or hospital? Do you think of the brick and mortar of the facility or do you just think of your endoscopy unit, your procedure room? What do you hear every time it's survey time is mentioned? Do you think about strangers walking through your facility, looking at everything with clipboards and writing it down? Do you think of all the hours you spent preparing documentation to show the surveyor of patient records, of employee files? Or do you think of individuals walking through the facility with ladders popping up ceiling tiles to examine the plenum space of the ceiling? Well, what do I think of? I think of the caregivers and all the assistance that I can render to our caregivers to ensure that they are promoting the health and safety of the patients and also of their fellow caregivers. So licensure, certification, and accreditation are all three methodologies of healthcare facilities to help them on their pathway towards ensuring excellent patient care. When we think of licensure, hospitals and ASEs must have a state license to operate. Requirements to obtain this license vary by location. They generally require an on-site survey prior to their opening and also require ongoing on-site surveys every year, usually conducted by the Department of Health of that said state. Also may include local jurisdictions as well. Certification, on the other hand, is a process in which healthcare entities are approved for participation in the federal payment program we know as Medicare and Medicaid. It's required by CMS for all healthcare facilities receiving their payments to undergo the certification process. It must be obtained to ensure providers meet applicable requirements for participation in the Medicare and Medicaid program and therefore are able to bill for their services. To be certified, these facilities must meet all the basic conditions of participation. Okay, these are basic conditions for participation that all facilities must meet. When we think of accreditation, accreditation is a voluntary process that organizations undergo to compare the quality of their services and operations against nationally recognized standards and other facilities. There are a number of accreditation associations. I myself deal mainly with the Joint Commission. However, I do work with a facility that has DNV for certification as well as AAAHC and also the American Association for Accreditation of Ambulatory Surgical Facilities. Accreditation also requires a written application prior to the on-site survey. It seeks to ensure patient safety and efficient operations. Surveyors, when they come, will observe patient care, review the organization's physical facilities, review policy and procedure manuals. We'll also look at patient charts, personnel files, and other records. They'll speak with clinical and non-clinical personnel as well as many patients. The focus of accreditation and the certification process as the CMS certification is the ground level, the basic standards which need to be met. Accreditation focuses on excelling the care that you give and improving the outcomes of the services you offer to the patients. Recently, CMS just threw a curveball to the accreditation organizations. They've listed three additional restrictions on the accreditation survey process. The first one being, as illustrated in the red box I have here, that CMS has forbidden accreditation organizations from providing any prior notification to organizations that a survey will be occurring. So, up to this date, we could look at, log on to our accreditation site, and we would know if a survey team was coming that day or not. This feature has vanished. Due to the fact CMS wants accreditation surveys to be a little bit more spontaneous and to catch people truly in the act. They have also forbidden organizations to place blackout dates for accreditation agencies not to be able to visit. So, more or less, to be able to control the dates that surveyors could come on campus. As you can see, this calendar illustrated blackout dates in red and also in the green boxes, dates which we could be surveyed. And the third one is that CMS will no longer permit accreditation organizations from investigating complaints that have been filed against those facilities virtually or online. All complaints need to be investigated in person. However, they haven't given a time frame how that will be done. So, survey compliance in our endoscopy units. The process is not unlike any process in other departments of the hospital. Survey readiness is really examining your facility, harvesting that low hanging fruit prior to the surveyor discovering it. So, we're not making the harvesting a little bit more difficult for the surveyor. We just want to ensure that we clean up our practices are within compliance prior to their arrival. So, maintaining survey readiness. We need to make accreditation readiness every caregiver's responsibility. It's a team event. It's just not up to managers or directors or presidents of organizations. It's all caregivers responsibility. What managers can do is review their past surveys and identify the gaps that were found in their practice by the surveyors. Initiate rounding on your unit routinely. Stay current with the standards of endoscopy practice. Maintain meticulous records of the inspection, maintenance, and the repairs of all the equipment and services done within your endoscopy unit. Again, this includes your endoscopes, your AERs, your cleaning accessories, all the devices that you have. Document your QI and PI projects. Have those available for the surveyor to review. Keep your credentialing and licensing files current, your HR files up to date as well, and also ensure protection of at-risk suicide patients, which is a national patient safety goal that has been cited quite a bit. So, survey readiness rounding is really a key to ensuring that you're up to speed and ready to take on the surveyor. It has many different facets. You want to look at the environment in which of your facility. Look at those life safety conditions of participation. We spoke about the infection prevention within the unit and also make sure that your medical records are up to speed and readily available to review. Accreditation is team sports. You want to pair up with your facilities and your biomedical engineering department, your infection preventionists, also your pharmacy services. Include an executive from the organizational structure, the leadership structure, so they are in tune to the needs and readiness of the department, and involve your frontline caregivers. For their eyes and their knowledge, a practical experience will go a far way, helping to close those gaps who are identified from the previous survey and improving and correcting them for your next survey. Now, rounding checklists can be easily created by and modified for your individual facility. All the accreditation agencies, Joint Commission, DNV, AAAHC, all have rounding checklists that you can copy and modify to custom fit your organization. So, these will greatly help in your rounding activities to score and find any areas of deficiency. They also highlight areas that you're doing well, and we need to celebrate our wins when they're discovered. Survey readiness, in general, is we covered the infection prevention practices that must be observed and adhered to. Another frequent finding by surveyors are expiration dates of medical goods. So, everything from IV catheters to IV bags, medication labels, expired dates of medications that are in service is a citable offense. They'll also go into our procedure rooms. They like to observe the universal protocol being performed. They like to make sure that all individuals involved in that procedure are engaged within that universal protocol. They want to ensure that there's a verbal agreement from the team on the procedure to be done. And they will ask staff if they feel comfortable in stopping the line and to repeat any answers if they have questions or if the answer is not complete. They'll observe for personal protective equipment to be worn. They'll also observe if it's worn inappropriate. So, often, and in the pandemic post-era, we see a lot of individuals walking around with headgear and face masks that are worn outside the procedural area. And we know this is to be doffed prior to leaving the procedural area. Again, they'll observe hand hygiene. Once they're walking through units or walking through the facility, observing hand hygiene is an easy component of the survey for them to score and to observe. I've mentioned QI and PI projects many times throughout this presentation due to the fact that their importance to show the surveyor you're striving to increase the level of patient care that you are given on your way towards excellence. Also, they can chew up a lot of valuable time during a survey. And also, they'll review contracts you have with various outside services. So, if you have a biomedical engineering department that's contracted to take care of devices in your ASC, they'll look at that contract. They'll look at pharmaceutical contracts if you have them, waste removal contracts, as well as medication, waste medication discarding contracts. Now, when we come to guidelines that are to be followed, accreditation organizations do not render direction towards applicable guidelines or standards which should be followed. So, organizations can choose upon themselves what guidelines and standards they wish to follow. Accreditation organizations will first and foremost ensure that the MIFU of the manufacturers are being followed. All right, I covered these standards of infection control in my previous talk. So, I want to highlight that when we looked at the frequency of citations, 40% of hospitals are cited for infection control practices, 30% of AECs, and 30% of office-based surgeries. And what are these findings, again, related to not adhering to the manufacturer's IFU, not following your own policies and procedures, improper storage of medical equipment, improper use of PPE, also lack of validation of skill level, incompetency of employees, also the lack of involvement of infection prevention in your programs, and lack of oversight of the governing body. Here are some additional standards that I didn't highlight, but there's HR standards that need to be satisfied. And this is the staff competency that is assessed. They're quite loose, and they give a three-year frequency. Though, when we look at some policies that we may follow and some standards, they recommend certain practices are validated by a skill checklist on a more frequent period, namely every year. Also, when we look at joint commission, I mentioned that the governing body is heavily cited within their review process, too, due to the fact that the governing body is ultimately accountable for the practices that occur within their facility. So, that's why it's always a good component to have these individuals as a member of your rounding team. Now, diving into survey readiness and helping to close the gaps during your rounding, one of the frequent findings we see is through the QC process of disinfectant test strips. As this picture illustrates that the expiration date of these strips is mismarked. This brand of test strips is good for 30 days, meaning nine, nine of September would be the appropriate date for these strips to be expired and thrown out. They'll also make sure that the QC process is done appropriately according to MIFU. You don't want to cut strips into pieces. So you're able to do tests with just one strip of your full strength, your weakened and your dilute solutions. Also, they'll check your QC log to ensure that that quality check is being performed. Delayed reprocessing is also an interesting venue that accreditation surveyors have tuned into. They're keenly aware now of the time that manufacturers have given for the time elapsed from pre-cleaning the endoscope to the commencement of manual cleaning. They'll look to see how this is communicated through various mechanisms from the procedure room to the reprocessing staff. So why is this important? This is important. So depending on the brand of endoscopes you use at that 60 minute period could be met and endoscopes don't lapse into an extended period where delayed reprocessing modality needs to be instituted. Most organizations will just write this time on the transport container that gives the reprocessing staff the ability to examine the scopes as they come in and triage which scopes are needed to commence with the reprocessing sooner. Transport of devices also is a highly measured standard. They're looking to ensure that there is not a chance of cross-contamination, looking at closed containers that are labeled appropriately with either clean scopes or use scopes that are labeled as biohazardous or contaminated. Puncture resistiveness of the containers is relevant until the jurisdiction that you're in, though they all need to be leak proof. The scope manufacturers all want single endoscopes placed within transport containers without any additional accessories. And these regulations are governed by OSHA for your records. They're also looking for standardized work instructions. So being able to post job aids in the procedure rooms for point of use care or placing reprocessing instructions within the manual cleaning room are excellent things to do. They're okay for staff to use references to assist them in their practice. It ensures that there is a consistent practice which is utilized. You can post these within procedure rooms and it also offers great visual instructions for our caregivers. Key areas in the high-level disinfection area that staff need to address is being able to clearly articulate policies and procedures and where they are able to find them. Also, they want to look and we'll examine that you have the up-to-date IFUs that are available to your staff. They will observe scope reprocessing. They will look to ensure that there is a dirty to clean flow within the reprocessing area. These savvy surveyors now carry the skill competency checklist of the major scope manufacturers. So they'll look to make sure that that process is being followed. The pre-cleaning is done correctly. That delayed reprocessing is invoked when necessary and the full gambit of reprocessing is done according to MIFU. I've mentioned logs numerous times for the filters, changes that are needed in our AERs and now in our scope cabinets. So many are investing in new technology with scope cabinets and with fans. So ensure that that scope cabinet fan is changed accordingly. I mentioned the MEC testing and also how that relies and plays into the replacement of the high-level disinfectant within the AERs. And they'll look to ensure that your equipment is serviced per the MIFU for any planned maintenance that is required. The environment of care or physical plant. Appearance matters a lot, right? They'll learn a lot just by looking at your institution and facilities. So we want to ensure that we store products correctly. That we're not impinging upon sprinkler systems by stacking cabinets too high. We're not propping open doors. We're not stopping egress by blocking various exits. So again, take pictures of your findings when you're around, share them during your huddles and staff meeting and hold accountable. Place work orders or for necessary repairs that need. Remove the clutter from your unit. And also food and drink in the patient care areas is also a highly noted offense. Make sure your log sheets are up to date on those PMs and temperature and humidity within designated areas. Now, life safety concerns play a big component of your unit operation as well. You want to ensure that your staff are readily know the fire plan, that they can locate the closest fire extinguisher and the fire alarms. So as you can see in these illustrations, that fire alarms and extinguishers can be hidden by all the equipment that we have within the department. And it's often easy for us to block fire doors. Are your records up to date? If you're a freestanding unit and you have that generator, has the generator log up to date? Has it been tested by the engineering department and endorsed to be up to speed? Are your eyewash stations up to snuff? Do you have protective caps on the eyewash components? Are they within 10 seconds of the potential splash zone? Are they not hidden behind doors? So you are permitted to have one door within the 10 second if it swings into the eyewash station. Survey readiness also includes your medical records. Make sure that your consents are complete. They're dated, their time, all applicable signatures are in place. That H and P's are updated. And if they are updated, the documentation is complete in all the appropriate areas. Care plans need to be up to date and also include timeframes for patient development. If interpreted services are needed for patients that their primary language is in English, you need to document the interpreter services were utilized or at least offered in those safe medication practices that surveyors love to hone in on. Labeling all medications when they're removed from the original container into syringes. Medication reconciliation if medications are wasted and discarded. And also the security of medications if they are properly secured according to state regulation. Personnel considerations is that their files hold most current privileges and credentialing. If you have certified staff, let the surveyors know that, that it is a step towards improving the overall operation efficiency and safety of patient care. We want to ensure that our orientation is well-documented as well as employees and caregivers ongoing continued education. Orientation competencies are well-documented and according to the frequency which they are performed. You want to, they may question who performed the competency assessment. Most units will have a subject matter expert, person who's trained by the company who will validate the skill level of those within the unit. They're looking to see if there are return demonstrations done during the competency assessment and that all new procedures hold competency checklist or when new equipment. And also as I shared in the previous talk when breaches have been identified. We have a whole talk about understanding the needs of diverse populations in your community. The accreditation organizations have taken a keen or interest into ensuring that healthcare facilities are meeting the needs of these individuals. Many facilities are making equity a strategic priority of their practice and they have formed such programs such as minority health fairs to help meet and collaborate with other community outreach programs to ensure diversity within the health field to prevent inequities of care. So when survey does arrive, it's your time to shine, okay? It's your turn to show off your facility to your survey team. Now, depending on your size, if you're a small AEC, you may just get a single surveyor, maybe a single surveyor with a life safety engineer who will look at different, will look at the building per se. Our last survey last August, we entertained 16 surveyors. So depending on the size of your facility will depend upon the number of surveyors you will visit, will visit with you. Though, when a surveyor comes to your department, to your endoscopy unit, they're going to observe a patient usually from the registration to a discharge period. The survey surveyor will observe at least one procedure being done. And through this procedure, again, they'll note the consents being signed. They'll also note a universal protocol being followed. They'll observe endoscope reprocessing to ensure it's done according to your procedure and policy. And more importantly, the MIFU. They'll review random patient charts and employee files for completeness and thoroughness. They will talk to staff, both medical staff, clerical staff, and other direct patient caregivers. They will also talk with patients regarding the care that they have received. So when you get word that the surveyors have arrived, you're going to invoke your survey readiness plan. You're going to do an environmental sweep of your unit, removing anything that shouldn't be there, that the food and drinks have been removed, right? Never a problem with Starbucks or Dunkin' being where it shouldn't be. Make sure that items are not blocking your medical gas shutoffs valves, your fire extinguishers, or your fire pool. Your medical gas cylinders are appropriately stored and identified as being empty or full. Those pesky outside shipping boxes have been removed from your storeroom. Ensure all efforts to protect confidential information. So we badge in, badge out of our EMRs appropriately. We don't leave the EMR up. If we do use paper, we ensure that the paper is placed with any identifiers down. And then when it's discarded, it's discarded into a waste reciprocal that's headed for shredding or into a protective disposal mechanism. Storage is a key component on those cabinets. You want to ensure that any item is greater than 18 inches away from that sprinkler head and the decluttering of the unit. You want to have one staff member available to assist each surveyor during that day. You want to prepare space for the surveyors to work. Often they'll request internet and computer access. Again, many of the surveyors are quite fluent in EMRs. CERNA, EPIC, provations, and can navigate their way. And we'll ask for privilege to be able to review through EMRs. If possible, correct any type of defect or citation that's found on the spot. Answer all questions honestly, but only answer the questions that they ask. Don't elaborate on a answer for them. And again, know those QI projects. Have your poster available. Have a staff member be able to readily express those to the surveyors. In practice, pearls of wisdom that I may offer you is preparation is crucial. Maintain survey readiness at all times. Perform those mock surveys, those tracers. Round in advance. Rounding should be a scheduled activity and be done on a routine schedule. Involve all clinical administrative and support staff in the process and have your partners in care, infection prevention, pharmacy, medical records, clinical engineering, visit your site and round with you. Due to the fact, if you prepare and get ready, it lessens the time you need to get ready. So stay ready so you don't have to get ready. And that concludes my talk.

accreditation

survey readiness

caregivers

CMS changes

survey compliance

infection control practices

diverse populations