As a nurse, a surgical leader, and a consultant, I have been through many surveys. I have been on the sidelines, assisted with readiness, been responsible for answering questions, and led the process. I have been through state, Medicare and accreditation surveys. They are never fun, and they can cause stress and anxiety. Some of the questions I have asked myself, and you may have too, include: Have I thought of everything? What did we miss? Will I be blamed if this doesn’t go as planned?
Here are some recent lessons learned, by both myself as well as colleagues. Hopefully, they can help you too:
- Multi-dose meds in patient care areas. Remember that multi-dose medications need to be treated as single dose medications in patient care areas. Anesthesia providers can sometimes forget this, and often will leave opened, dated (with good intention) medications in their carts. I recommend assigning a nurse to check all medication storage areas for open medications in patient care areas, just in case.
- Policies that reflect processes. As you are reviewing key policies, remember to make sure they match your processes. I have recently read policies that refer to non-existent committees, meetings, and activities. It is a difficult challenge that can be avoided with some simple policy revisions.
- Updated Staff Files. Ensure that all of your staff files are up to date, including new and occasional prn staff. Time always flies when we are busy. It is Murphy’s Law that the surveyor will ask for your newest staff member’s file, or that prn staffer that never works, and the files are not up to date with training and education. Mark your calendars to ensure that new staff files are complete on time, and make seldom used prn staff files inactive until they are scheduled to work again, with the understanding that they need to be compliant to be scheduled. If you struggle with getting everyone trained on all the required elements, I’ve created ALM Solutions Academy, an ASC online education resource. If you’d like to check it out, you can find it here.
- Peer Review. Make sure that your Peer Review activities are included your re-credentialing process. I have a statement that is included for check off that states the peer review activities have been reviewed as part of the re-credentialing decision by the governing body.
- Out of range temps. Do your fridge thermometers include alarms when out of range? Can you review problems from when the facility is closed? Make sure that your thermometers provide information when temps are out of range, and this information can be reviewed upon return to facility after a weekend or holiday. While you’re at it, make sure that your logs include acceptable ranges and an area to document out of range activities. With the recent hospital freezer storage nightmare, this may become more of a focus during surveys. If you don’t know about the freezer issue, You can find the link to the story here.
- The dreaded housekeeping closet. Often, we use cleaners that need to be diluted. I recommend posting dilution instructions, as well as a measuring cup to support the appropriate diluent to solution ratios. I’ve seen centers cited for not having this information accessible for staff. While you’re checking the housekeeping closet, make sure items are off the floor and stored appropriately, and that only EPA approved cleaners are being used for facility housekeeping.
- Storage. I’ve had facilities cited for: Cardboard in sterile areas, for sterile supplies being stored with non-sterile supplies, and for items stored on floors, not to mention expired supplies. Assign staff to storage areas to check and correct all the above. Need to get items up off of the floor? I found some inexpensive risers here.
With any survey, don’t worry about being perfect. My motto is review, prepare, then review again. Learn from the process. It’s never fun, but in the end, you will know you meet all the requirements, and feel accomplished.
Need help with an upcoming survey? We’d love the opportunity! Find us here!