Improving Quality and Safety in the Endoscopy Unit (Virtual) | August 2023-Preparing for a Successful Endoscopy Unit Survey Accreditation

Video Transcription

Video Summary

In this video, the speaker discusses the mechanisms necessary to achieve accreditation in healthcare facilities. They explain the concepts of licensure, certification, and accreditation, and emphasize the importance of maintaining survey readiness. The speaker highlights the need for teamwork in achieving accreditation and involving all caregivers, not just managers or directors. They discuss various aspects that surveyors look at during a survey, including patient care, physical facilities, policy and procedure manuals, patient charts, personnel files, and more. The speaker also covers recent changes in the accreditation survey process, including the prohibition of prior notification to organizations, restrictions on blackout dates for accreditation agencies, and the requirement for in-person investigation of complaints. They provide recommendations for maintaining survey readiness, such as reviewing past surveys, staying current with standards, maintaining records, and involving various departments in the process. The speaker also covers specific areas that surveyors focus on, including infection prevention, expiration dates of medical goods, universal protocol, high-level disinfection, staff competencies, medical records, and personnel considerations. They provide guidelines for survey readiness rounding and discuss the importance of adhering to standards and guidelines. The speaker concludes by emphasizing the need for preparation, maintenance of survey readiness, and involving all relevant stakeholders in the accreditation process.

Asset Subtitle

Jim Collins, BS RN CNOR

Keywords

accreditation

survey readiness

patient care

personnel files

infection prevention

medical records

standards