Three years ago Newport Bay Surgery Center, in Newport Beach, CA had ZERO deficiencies on their HFAP accreditation, Deemed Status survey. NBSC is managed by PSS and I have served as the Administrator since it’s opening in 2007.
The survey window for the triennial resurvey opened in late August. This was our third survey cycle. We approached it with confidence, tempered by the reality that it was unlikely we could repeat our last performance. As a national ASC consultant, I can tell you a ZERO deficiency survey report is a rarity since the expansion of the Medicare regulations in 2009. We work with hundreds of ASCs, most well prepared yet the surveyors always seem to come up with something…
The surveyors arrived Monday, which was the first surprise. We assumed they would not travel on the weekend. We scored two nurses. In my experience, nurses are the toughest surveyors, because they know the most about the ASC clinical environment. They were thorough in their assessment. We had at least 12 clinical staff members working each day of the survey and the surveyors managed to have interactions with more than half of them. We always tell our clients, anyone working on survey day is fair game to a surveyor. That’s why staff education and training is SO IMPORTANT!
Vanessa Sindell, RN, Clinical Director, handled the survey process masterfully. She and her charge nurses had spent time together reviewing each of the 420 HFAP ASC accreditation standards and the CMS ASC Conditions for Coverage. They were well prepared and could point to chapter and verse of their policies and procedures to support their compliance.
Since our launch, we have conducted an all day annual mandatory education day and we have a thorough orientation process for new employees. We strive to make sure ALL the clinical staff is knowledgeable and competent when it comes to implementation of standards, regulations, policies and procedures.
Our combined efforts paid dividends on our survey. We scored another ZERO deficiency survey report!! The surveyors were complimentary about many things. They interviewed a new nurse employee, asking her about her orientation and training. They told her she was lucky to work in such a warm and friendly environment obviously committed to quality. The surveyors were impressed with our commitment to staff training and said the results were obvious and in sharp contrast to many other centers. They complimented us on the environment we have created, so conducive to interdisciplinary interaction, which ultimately enhances patient quality and safety.
According to Vanessa Sindell, “It’s really not that hard. The Progressive Surgical formula works! If you use Progressive Surgical eSupport, and follow through with implementation of the guidance and resources available there, it’s a slam dunk.”