OR Manager August 2022 - 25

AMBULATORY
SURGERY CENTERS
an Excel-type spreadsheet. " Every single
policy that you have should have been
approved by the governing body, " he
adds.
Credentialing and privileging are also
aspects of governance. It varies from organization
to organization. What AAAHC
wants to ensure is that a facility has a
credentialing and privileging program
that works for them and that this program
is done within the organization and
is not outsourced to the hospital or to a
consultant.
" Another tip, " says Dr Shapiro, " is
to make sure that physician privileging,
and all aspects of the process, are specific
to your facility. "
For example, says Kleinhesselink, if
an organization lets nurses provide IV
sedation under the direction of the surgeon,
anesthesiologist, or a physician
in the room, that allowance should be
compliant with state and local regulations,
and it must also be documented.
Peer review also comes under governance,
and two problems that Kleinhesselink
says facilities have are ongoing
monitoring and getting peer review incorporated
into the reappointment process.
Dr Shapiro notes that there are two
aspects of peer review that he encourages
organizations to incorporate-one
is that it be an ongoing process, and
the other is the inclusion of any unusual
occurrence or incident.
" Not only do you want to do your investigation
and your quality assurance
and root cause analysis, but you also
want to make sure that it is one of the
nonrandom selections for peer review
for that physician or physicians involved
in the occurrence, " he says. " Make sure
you have both of those components. "
Chapter 3: Administration
Administration comes down to supervision
of the organization, says Kleinhesselink.
www.ormanager.com
A
big part of this chapter is:
* documentation
* administrative responsibilities
* patient satisfaction
* policies and training.
" My first tip, " says Kleinhesselink,
" is don't trip yourself up on policies and
procedures. " When surveyors come to a
facility, they look at AAAHC standards,
Centers for Medicare and Medicaid Services
(CMS) standards if it is a deemed
status survey, and the facility's policies
and procedures. " If your policies
and procedures are more stringent than
AAAHC and CMS standards, we will hold
you to your own standards, assuming
that they are compliant with prevailing
regulations, " she says.
Fiscal controls in place to protect
assets, specifically cash flow, are another
point facilities stumble on. " An
unfortunate, but common, issue a lot of
facilities experience is fraud, especially
with the transmission of cash, " says Dr
Shapiro. " We're not telling you what fiscal
policies to have, " he says, " but we
want to verify that organizations have
the financial viability to deliver quality
patient care and comply with applicable
requirements. "
There are some requirements in this
chapter for orientation and training of
new staff that need to be completed
within their first 30 days, including disaster
preparedness, emergency equipment,
information technology, and risk
management. " We are not going to tell
you how to do it. We're just going to
ask you to tell us how you did it, and to
show us where it is documented in personnel
files, " says Kleinhesselink.
Much like the credentialing form,
there is also a personnel form in the
AAAHC handbook. " It is the exact same
form the surveyors will use, so you will
know everything surveyors are going to
look for, " she says.
Chapter 4: Quality of care
provided
Quality of care is what is driving this
entire process of accreditation, says Dr
Shapiro. It is intentionally not specific
because all organizations are different.
" We're not going to come in and say:
'This is the only way that you must ensure
quality of care for your patients.'
Instead, we're going to ask you how you
are ensuring quality of care for your patients
and let you tell us, " he says.
Surveyors want to make sure everyone
is trained appropriately and that
they do not feel pressure to do something
they do not feel competent doing.
" We really want to work with you and
ask you in an open-ended manner how
you are going to make sure everyone is
well-trained and competent to provide
the types of care they are providing, "
says Dr Shapiro.
Kleinhesselink adds that one area
where people slip up is when their policy
says everyone in the organization is
going to have Basic Life Support (BLS)
training. " If you say: 'Everyone in our
organization is going to have BLS,' then
we are going to expect that everyone in
your organization has BLS, " she says.
Another aspect of this chapter that
still trips up a lot of facilities is medication
reconciliation, says Dr Shapiro.
For example, diabetic patients may be
told to hold their insulin before their
surgical procedures. However, they may
not understand that they are to resume
their regular insulin schedule after they
leave, and they can end up in a diabetic
coma. This is an extreme example, but
it has happened, and illustrates the
importance of medication reconciliation,
he says.
Kleinhesselink notes that she was at
a facility where she was told they do not
do medication reconciliation because
they do not administer any medications.
Continued on page 26
OR Manager | August 2022 25
http://www.ormanager.com
OR Manager August 2022

Table of Contents for the Digital Edition of OR Manager August 2022
