Arkansas Specialty Surgery Center

Challenge

Lack of internal ASC-specific expertise was hampering the timely resolution of existing deficiencies.

Solution

Regulatory Compliance Mock Survey by ASC Advisory Services from SourceMed, now Surgical Information Systems (SIS).

Results

• Transitioned existing hospital-centric policies and procedures to an ASC focus
• Changed staff behavior through ASC-specific education and training
• Ensured continual improvements through long-term partnership with SIS

“For centers that are unable to take on the work internally [to prepare for a AAAHC certification survey], you can’t just coast along hoping the problems will solve themselves. Over time things will only get worse. Outsourcing to an ASC expert like Ann Geier is the way to go.”

— Norman Burnette, CPA, CASC, Administrator, Arkansas Specialty Surgery Center

Situation

Obtaining the Accreditation Association for Ambulatory Health Care (AAAHC) certification is an arduous – but critical – process for Ambulatory Surgery Centers (ASCs). The accreditation certificate is a symbol that a facility is committed to providing high-quality care and that it has demonstrated its commitment by measuring up to nationally-recognized standards. However, the sheer volume of information that must be reviewed within the Standards Manual and the tasks required to achieve certification can be daunting. Regulatory compliance mock surveys, usually conducted by a neutral third party, simulate an actual survey experience.

They are an excellent way to make sure new ASCs facing their first AAAHC certification and existing centers renewing accreditation are adequately prepared for the survey by identifying areas for improvement and deficiencies. 

Arkansas Specialty Surgery Center

Arkansas Specialty Surgery Center opened in 1998. In 2013 a Centers for Medicare and Medicaid Services (CMS) survey uncovered several deficiencies at the center. Nearly three years later, Norman Burnette, CPA, CASC was brought on board as the center’s new Administrator. After assessing the situation, he discovered many of the issues uncovered during the CMS survey still existed, and additional ones had arisen.

Arkansas Specialty hired SIS Chief Nursing Officer Ann Geier, MS, RN, CNOR, CASC to conduct a mock survey and assess the situation. During the mock survey Ms. Geier confirmed the issues that remained were significant. She determined that most issues were largely the result of a lack of internal ASC-specific expertise. Because the management group and most of the staff at the center were from a hospital or physician clinic environment, the policies and procedures were developed for a hospital environment, not an ASC.

“Having been in the industry over 18 years, there are very few individuals I would put in the same category as Ann Geier. Ann is an ASC expert among experts. She has a broad-based knowledge and understanding of the ASC industry that is very difficult to find.”

Education Matters

Because of her extensive ASC experience, Ms. Geier knew that simply telling management about the issues she had uncovered during the mock survey and recommending corrective actions would not be enough to change ingrained behaviors and processes. The team at Arkansas Specialty needed to understand what they were being asked to do and why. Ms. Geier drew upon her deep knowledge of the rules and regulations of running an ASC to provide the necessary insight. She provided a comprehensive overview of the ASC reporting requirements necessary for regulatory surveys and offered insight into critical issues that needed attention. For example:

• Patient safety is a top priority at Arkansas Specialty. Ms. Geier explained that even though Arkansas Specialty has an excellent patient safety record, without proper documentation it would not matter in the eyes of a surveyor. More than just saying documentation must be done properly and writing policies and procedures for staff to follow, she educated staff and management on why they must do things a certain way which dramatically increased compliance.
• A hospital OR and an ASC run very differently. Because Arkansas Specialty staff are primarily hospital employees leased from the center’s sister facility, and the management company’s expertise was limited to physician clinical operations, most of the policies and procedures at the center reflected hospital operations. Ms. Geier worked with the team to tailor and implement the proper policies, protocols and procedures for an ASC setting, which is key to obtaining AAAHC certification. During the process, she took the time to ensure staff understood the differences and why ASCs have unique requirements.

“The very detailed explanations Ann used to educate our team on the significance of each issue and the impact to our center were extremely valuable to gaining buy-in for what we needed to do. Her approach also helped accelerate the resolution process.”

A Long-Term Partnership

A tremendous amount of work is required to resolve issues uncovered during the CMS survey and subsequent mock survey at Arkansas Specialty. While progress has been made, several of the larger issues are still being addressed. Ann Geier has been retained by Arkansas Specialty to continue working with staff and management to guide the team as they continue to work on fixing deficiencies for the long-term.

According to Burnette, “For centers that are unable to take on the work internally, you can’t just coast along hoping the problems will solve themselves. Over time things will only get worse. Outsourcing to an ASC expert like Ann Geier is the way to go. We have been very impressed with Ann’s knowledge and expertise including her approach to resolving issues and tasks to bring our ASC into regulatory compliance. Ann’s service is invaluable and will be beneficial to others in this industry.”