OR Manager August 2022 - 27

AMBULATORY
SURGERY CENTERS
mentation on how you're providing care.
We want to see organization. We want
to see consistencies. We want to make
sure you cover the important details. "
One thing, Dr Shapiro says he has
noticed when reading clinical records is
that a lot of different people ask about a
patient's allergies, including the admitting
nurse, preoperative nurse, surgeon,
and anesthesiologist. " It's disturbing
when I go through the chart and see
different allergies in different places for
the same patient for the same time, "
he says. " That leads me to believe that
we haven't gotten a good allergy history
from the patient. "
As an anesthesiologist, he says he
does not want to try and figure out in
recovery why the patient had an anaphylactic
reaction. " Overall, " he says, " we
want to make sure that all of the good
things you are doing in the course of
every patient experience in your facility
are documented consistently and accurately
throughout your records. "
Dr Shapiro also notes that it is the
surveyors who will pick the records to
examine during a survey. " Surveyors
want to look at random records, not
just records that are in good shape and
chosen by a person in charge of the records, "
he says.
In addition, surveyors want to look
at anything that was considered an incident
or adverse event, how it was handled,
and how it was documented.
Chapter 7: Infection prevention
and control and safety
Chapter 7 says an accredited organization
protects patients and staff, has a
written infection control program, and
has an individual in charge of that program,
says Kleinhesselink.
" You have to have a written infection
control plan, and it has to be approved
by the governing body,
like everything
else, " she says. The person in charge
of the program does not have to be
certified in infection prevention but does
need some education and needs to be
www.ormanager.com
able to speak to it. That person also
needs to show documentation of ongoing
infection prevention education for
the staff.
In addition, the program needs to be
based on nationally recognized guidelines,
such as the Centers for Disease
Control and Prevention, AORN, or the
Association for Professionals in Infection
Control and Epidemiology, and it
has to be incorporated into the organization's
quality improvement program.
There also may be state, federal, and
tribal requirements for this program.
" Infection prevention covers every
aspect of everything you do, " says Dr
Shapiro. " We are not just going in there
to look at a policy, we are going to look
at how clean your facility is and how
you are cleaning instruments, equipment,
and furniture between patients, "
he says.
" Your staff should also know they
should be following manufacturer guidelines,
and they should be able to speak
to it, " says Kleinhesselink.
Also under this chapter is safety.
" It's a bit like house management in
that you are going to manage hazardous
threats, " says Kleinhesselink. " Safety
comes at it from a very proactive approach, "
she says. " You want to have
processes in place to reduce the risk of
things like patient falls and skin injuries,
and we will look for a written safety program. "
Other
parts of a safety program include
having a policy to check for expiration
dates on items such as medications
and sterile supplies, a policy for
what to do with devices and drugs that
are recalled by their manufacturers, and
a policy for disposing of hazardous materials
and contaminated items.
Chapter 8: Facilities and
environment
This chapter describes how an organization
provides a functionally safe and
sanitary environment for patients, personnel,
and visitors.
Emergency drills are a part of this
chapter. " We don't want you to do them
all the week before the survey. What is
important is not only the scenario-based
drill, but what you do in response to
what you have found during the drill. We
want to see documentation of all this, "
says Dr Shapiro.
For scenario-based drills, he says
one of the things he sees lacking is a
description of the scenario. " It doesn't
have to be a dissertation with pages
and pages.
It can be something like:
'The patient was in the bed. He threw a
match into the trash can. There was a
fire,' " he notes.
Please be aware that these drills are
meant for what they are intended, which
is patient safety, says Dr Shapiro. " I
know they are hard. I know they ask you
to do a lot. But please be diligent about
doing them because in the end, it will
really benefit your facility, your staff, and
your patients. " ORM
-Judith M. Mathias, MA, BS, RN,
is clinical editor of OR Manager.
Previously, she was clinical editor
of the AORN Journal and a cardiac
surgical nurse at Rose Medical Center,
Denver, and Massachusetts General
Hospital, Boston.
Reference
Kleinhesselink J, Shapiro D M. Preparing
for AAAHC accreditation. ASCA
2022.
For more information on AAAHC accreditation or to purchase a copy of their
handbook for ASCs, visit www.AAAHC.org. To learn more about the accreditation
process, enroll in AAAHC's " Achieving Accreditation " conference (https://
www.aaahc.org/accelerated-readiness/achieving-accreditation/conference/).
OR Manager | August 2022
27
https://www.AAAHC.org https://www.aaahc.org/accelerated-readiness/achieving-accreditation/conference/ https://www.aaahc.org/accelerated-readiness/achieving-accreditation/conference/ http://www.ormanager.com
OR Manager August 2022

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