Ambulatory Surgery Center (ASC) expert accelerates resolution process through mock survey and hands-on education, and Resolves AAAHC Certification Deficiencies.
Specializes in orthopedic surgery and pain management.
Lack of internal ASC-specific expertise was hampering the timely resolution of existing deficiencies.
Regulatory Compliance Mock Survey by ASC Advisory Services from SourceMed, now Surgical Information Systems (SIS).
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 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.
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:
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.”
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An outside ASC expert was needed, within a short timeframe, to help review policies and procedures for Standards' Compliance in a new ASC.