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

10_ASGE Quality_Collins_Accreditation

Pdf Summary

This document is a presentation by James Collins, an Enterprise Endoscopy Accreditation Professional at the Cleveland Clinic in Cleveland, Ohio. The presentation aims to provide information on how to be prepared and successful for endoscopy unit survey accreditation.<br /><br />Collins begins by defining licensure, certification, and accreditation, explaining that hospitals and ambulatory surgical centers (ASCs) must have a state license to operate, and certification is required by the Centers for Medicare and Medicaid Services (CMS) for participation in federal payment programs. Accreditation, on the other hand, is a voluntary process that allows organizations to compare the quality of their services against nationally recognized standards.<br /><br />To maintain survey readiness, Collins suggests that accreditation readiness should be the responsibility of every caregiver. He emphasizes the importance of reviewing past surveys to identify any gaps and rounding on the unit to ensure compliance with standards. Additionally, keeping meticulous records of equipment inspection and maintenance, documenting quality improvement and performance improvement projects, and ensuring the protection of at-risk suicide patients are essential for survey readiness.<br /><br />Collins also highlights key areas that need to be assessed during a survey, such as infection prevention, medical record review, and the involvement of a multidisciplinary team that includes facilities, biomedical staff, infection prevention, and pharmacy.<br /><br />The document provides guidelines and standards from various organizations related to reprocessing flexible gastrointestinal endoscopes, infection prevention, and flexible endoscope reprocessing in healthcare facilities. It emphasizes the importance of adhering to manufacturer instructions for use (IFUs) and implementing proper infection prevention and control plans.<br /><br />Other topics covered include the environment of care, life safety, medical records, personnel considerations, and understanding the needs of diverse populations in the community.<br /><br />During a survey, accrediting agencies will trace a patient's journey from registration to discharge, observe procedures and endoscope reprocessing, review patient charts and employee files, and conduct interviews with staff and patients.<br /><br />The presentation concludes with a section of practice pearls, including questions to test understanding.<br /><br />Overall, the document provides a comprehensive overview of how to be prepared and successful for endoscopy unit survey accreditation, covering various aspects of compliance and best practices.

Keywords

endoscopy unit survey accreditation

accreditation readiness

survey readiness

infection prevention

medical record review

multidisciplinary team

reprocessing flexible gastrointestinal endoscopes

manufacturer instructions for use

patient journey

compliance