Thank you, Sufjan. I took a lot from your talk, and now I have great pleasure of addressing everyone's favorite topic, preparing for an accreditation. So as before, I have no financial relationships to disclose. So let's start with a polling question. My practice or unit is accredited by? Okay. It's pretty much what I figured. So time sensitive requirements. So you're supposed to be reviewing your policies and procedures once a year. You want to make sure that the governing body meetings are meeting according to your own bylaws and policies. So if your bylaws and policies state you're meeting every month or three times a year, you want to make sure that you're meeting that three times a year or every month according to your policy. You want to have a periodic review of accreditation requirements. You want to make sure that date sensitive licensure and certifications such as your ACLS, your BLS, medical licensures, your DEA license, you want to make sure that those are all current and up to date. You want to have ongoing nature of data collection for peer review. You want to ensure review of the application includes integration of peer review. Time sensitive appointment and reappointment, especially important if your practice is adding a new provider, they cannot start practicing until they have been approved. So you will probably have to have a board meeting to approve that. I've seen most practices now have some type of electronic service that sends reminders out to the positions and staff in regards to what's coming up to expire. So that does help alleviate the last minute runaround. So QI or QAPI, quality assurance and performance improvement. You want to make sure you have a well-written quality improvement plan and you want to make sure if you haven't done so already, you've updated it for COVID-19. The QAPI program must set out priorities. It should look at high risk, high volume, problem prone areas, which are now considered to be PPE and hand hygiene. You want to make sure your staff and your physicians are doing this correctly. You want ongoing data collection of quality indicators and other aspects of patient care. You should have ongoing data on things like adverse events, patient satisfaction, day of surgery cancellations, ongoing analysis to measure quality and quality related problems. Your QI activities, that they're ongoing, including the QI studies, the QI team should be providing progress reports to the quality management committee on a quarterly basis. Time sensitive requirements for your staff. The initial orientation should be done within 30 days of the date of hire. And this is very important because this is where that staff is going to get their initial training on infection control policies, which now is very important that the staff is up to par, especially the COVID-19 items. You want to make sure annual competency requirements are met. Remember if you didn't document it, you didn't do it. You want to have documented training in policies and procedures as needed. So if you make any changes at any time to any of your policies and procedures, you need to have documented training from your staff and your practitioners. You also want to make sure that the current certifications for them, the BLS, their ACLS, and PALS if applicable, are up to date. Facility issues. And the monthly inspections of the fire extinguishers, make sure that's documented. Documentation of their annual reviews, you want to make sure that they're documented and they're signing off on it. You want to have quarterly scenario-based emergency drills and make sure there is a written evaluation of your drill. Inspection of medical equipment, you want to make sure Biomed is inspecting the equipment according to your schedule. And you also want to make sure that that is documented. Maintenance and temperature logs. This is very important. And I find that staff here, they need to be knowledgeable in what to do if something in the temperature log is out of range. During my experience with inspections, that's usually one of the things that the inspector finds. If they come in, they'll look at your temperature ranges and see that on two occasions it was two or three points above and staff never documented what they did. So again, if you didn't document it, you didn't do it. Fire suppression systems are tested accordingly. If you have sprinklers, you want to make sure those are tested accordingly as well and documented. Any illuminated exit signs are verified to be in working order and documented. Risk management. Refusing care to patients. So basically, you want to make sure that if your facility is not accepting COVID-19 patients, you need to make sure that your policy has been updated if you haven't done so already. You want to have a written policy on incapacitated healthcare, incapacitated or impaired healthcare professionals. On a side note, I found that this is actually a very good drill to conduct with your staff because this is something that most people don't think will ever happen, but it's actually something that is important and that your staff should be aware of what to do during those times. Grievance policy. You want to make sure that the grievance policy addresses ongoing review of the complaints and grievances received. You need to have a defined response time, and you want to make sure you have your follow-up documented. Definition of an incident includes any clinical or non-clinical occurrences that is not considered to be routine care or operation. You want to make sure that this definition is within your policy. It's clear and concise. You want to make sure whatever you define as an incident is written in your policy. And again, all changes to plans, programs, or policies and procedures must be approved by the governing body and documentation of staff and provider training prior to the implementation. So emergency and disaster preparedness plans. If you haven't done this already, you want to make sure that your plan addresses pandemic considerations. That needs to be updated. The plan is to be based on your community-specific risk assessment. You have your risk assessment, but you also need to have your risk assessment for COVID-19 as well. Again, scenario-based drills of the internal and external emergency, disaster, and preparedness plans are conducted. And again, you want to make sure you have a written evaluation of each drill that is completed. This way, you can find areas that you need to improve in. There's always room for improvement. Infection control and prevention program. So basically, you want to make sure your organization has conducted a documented infection control risk assessment, including COVID-19. And the updated program is based on nationally recognized guidelines. The updated plan has been approved by the governing body as well. There needs to be documentation, needs to be documented evidence of the training for staff and providers. In regards to cleaning, decontamination, high-level disinfection, and reprocessing of endoscopes, you want to make sure you're adhering to those nationally recognized guidelines, state and federal guidelines. The IFUs, the manufacturer's instructions for use. You want to make sure that you have your IFUs readily accessible for your staff. So what I do is we have them electronically, and we also have them printed out and placed in books, and they're kept at the location of the area that those items are being used. So it's easily accessible for the staff. You want to have a written policy in place for monitoring and documenting the process. So in regards to infection control and prevention, you want to make sure your plan has addressed a process for your staff or provider exposed to COVID-19. If the organization conducts COVID-19 tests, do you have the required license? So you need to make sure if you're doing COVID-19 testing that you have the required license for your facility. Make sure your plan includes contact tracing to determine if infections occurred in your facility. You need to have a process for disposing of hazardous and contaminated waste and that it has been reviewed and approved. PPE requirements have been reviewed and updated as needed. Documentation that your staff is trained is so important. So it's good to have documentation of your staff donning and doffing the PPE. I find that very helpful to do a return demonstration with your staff on this, show them what to do, and then have them return that demonstration and check off on a competency and document that they've been trained. It works really well. Remember, if you didn't document it, you didn't do it. Remember, you want to review your accreditation manual and make sure all your written requirements are there chapter by chapter. The QI Risk Management Program, Emergency and Disaster Preparedness Plans, and the Infection Prevention and Control Program will require review and updating as well as documentation of training. And remember, once you update your plans, you do need to make sure you update your policies as well, and they need to be approved by the governing body. So when it comes to inspections, I can't stress it enough, I do it to myself. You want to prepare for your inspection pretty much every day. Include your staff in preparing for your inspections. I like to give my staff quick meetings and go over the key points during inspection time and what they can be prepared to answer questions and what the inspectors will look like. I think that really is important and it does help engage your staff and keep them involved. So when that day does come, they are fully prepared on what to do. Thank you.

accreditation preparation

policies and procedures

peer review

staff training

emergency preparedness