1. May 29, 2019

Surveyors Detail Four Common ASC Compliance Issues

Common compliance issues for ambulatory surgery centers (ASCs) include quality improvement studies, credentialing and privileging, documentation management, and life safety and emergency management, according to an article in Ophthalmology Management. The article details reports from two ASC accreditation organizations.

Quality improvement programs are mandated by all standards overseeing ASCs and should demonstrate that an ASC is making improvements. If a problem occurs frequently, performance falls below a benchmark, or a potential problem is identified, a quality improvement study should be conducted. One problem often cited by surveyors is that quality improvement studies do not specify a measurable goal indicating improvement.

An area of low compliance in ASCs is credentialing and privileging. All individuals providing medical services in an ASC must have their credentials reviewed, and reappointment is needed before expiration of privileges. Although most facilities comply with initial credentialing, recredentialing and reappraisal are often overlooked. Not adding new equipment or procedures to the privileging list can also cause an ASC to be declared deficient.

Surveyors also use written documentation to ensure ASC compliance. Centers for Medicare and Medicaid Services (CMS) requires all patients have a comprehensive history and physical examination within 30 days of surgery in an ASC. This information must be updated in the ASC’s clinical record and physician’s office records. To help ASCs comply with proper documentation, it is recommended to develop a meeting minutes template including topics the board is required to discuss.

Recent updates to life safety and emergency management standards have also caused compliance issues. In addition to clinical standard compliance, ASCs must be aware of building safety standards and facility compliance. Common issues include generator maintenance, exit light placement and function, fire wall integrity, and fire suppression and alarm system maintenance. ASCs must have an emergency preparedness program with an assigned staff member responsible for developing the program. Noncompliance is often the result of no defined accountability.

Monte Jay Goldstein, MD, a surveyor for CMS and American Association for Accreditation of Ambulatory Surgery Facilities, anesthesia chief for the Jandee Anesthesiology Division of Envision Healthcare, and medical director at Ramapo Valley Surgical Center in New Jersey, notes that “the governing body and staff should never assume a standard doesn’t apply to them. Preparation for survey should always be in progress. If for some reason there is a lack of understanding of a standard, seek out additional resources, of which there are many, for assistance.”

Reference:

Ifft D. Your ASC inspection through the eyes of surveyors. Ophthalmology Management. 2019;23:12-18.