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Carolina Coast Surgery Center
Carolina Coast Surgery Center

Carolina Coast Surgery Center

AAAHC Certification is achieved through mock survey, as Ambulatory Surgery Center (ASC) expert Ann Geier ensures accuracy and compliance for new ASC’s initial accreditation.

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About Carolina Coast Surgery Center

Opened August 2015 as a full-service ambulatory and outpatient orthopedic surgery center.

Location: Murrells Inlet, SC
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Challenge

An outside ASC expert was needed, within a short timeframe, to help review policies and procedures for Standards Compliance.

Solution

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

Results

  • Achieved AAAHC/Medicare Deemed Status on first attempt
  • Completed training more quickly and cost effectively
  • Prepared and thoroughly educated staff
“Partnering with a highly experienced, AAAHC-certified expert like Ann Geier ensured no policy or task was overlooked. The time saved by enlisting the help of Ann allowed us to focus on the many other details involved when opening a new ASC.”

— Tammy Andrews, CASC, Administrator, Carolina Coast 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 by identifying areas for improvement and deficiencies.

New ASC Enlists Expert Help

Carolina Coast

Carolina Coast Surgery Center opened in August 2015. With a management team previously unfamiliar with surgery centers, all of Carolina Coast’s policies and procedures were the responsibility of the Administrator, Tammy Andrews, CASC. The task at hand was challenging. As a new center, everything had to be developed from scratch, and the timeline was short.

“As the management company’s first ASC, we wanted to make Carolina Coast a showcase facility. Obtaining AAAHC Certification on the first try with no conditions was a top objective, but we had limited resources and a tight deadline. We decided that bringing in an industry expert to help us prepare was necessary to achieve our goals,” says Andrews.

“Obtaining AAAHC Certification on the first attempt with no conditions was a top objective, but we had limited resources and a tight deadline. We decided that bringing in an industry expert to help us prepare was necessary to achieve our goals.”

Enlisting Expert Help

When opening a new center, it is easy to overlook critical tasks. In anticipation of AAAHC certification, Carolina Coast felt a mock survey would increase its chances of success. Although Ms. Andrews had been through surveys in the past, having an outside expert perform a mock survey meant a fresh set of eyes to make sure nothing was missed or done incorrectly.

Having heard SIS Chief Nursing Officer Ann Geier, MS, RN, CNOR, CASC speak at industry events and being impressed with her deep ASC-specific business and clinical knowledge, including AAAHC training and accreditation, Carolina Coast contacted her to inquire about mock survey services. Able to meet the center’s tight deadline, Ms. Geier began working with the team immediately. To speed things along, Ms. Geier provided Carolina Coast’s staff with a list of items to review and complete before her visit.

Preparing for Success

Once onsite, Ms. Geier asked for all the documentation a surveyor would request, including random charts and credentialing files. More than simply making sure the right policies and procedures were in place, Ms. Geier spent significant time educating staff on what to expect during the actual survey and how to prepare. This was a huge benefit to the team, especially the nurse manager who had not been through AAAHC certification before. It was also an excellent refresher for those that had already been through the process.

From start to finish, the mock survey took a day and a half to complete and did not interfere with day-to-day operations. The center’s administrator and nurse manager worked closely with Ms. Geier while the rest of the staff were able to continue taking care of patients.

Ms. Andrew notes: “While many people out there are eager to conduct a mock survey, they often lack the experience and insight to help ASCs achieve accreditation. Ann is highly experienced and knew the specific policies and processes we needed to have in place.”

Because Ms. Geier knew exactly what the AAAHC surveyor would ask, several important areas to address were identified during the mock survey, for example:

  • It was discovered the physicians did not have the required fire safety training. Ms. Geier provided a training template that she uses with other facilities which meant staff did not have to spend time reinventing the wheel. Having this model in hand allowed training to be completed more quickly and cost effectively.
  • Policy numbers were clearly written next to each standard within the Standards Manual at the recommendation of Ms. Geier. Doing so enabled staff to pull policies quickly when the surveyor requested them. In some instances, hard copies of policies were prepared in advance so that they would be readily available when requested.
“While many people out there are eager to conduct a mock survey, they often lack the experience and insight to help ASCs achieve accreditation. Ann is highly experienced and knew the specific policies and processes we needed to have in place.”

Time Well Spent

Because Carolina Coast was well prepared, thanks in part to Ms. Geier, the center achieved AAAHC/Medicare Deemed Status on its first attempt in September 2015. According to Andrews, “Partnering with a highly experienced, AAAHC certified expert like Ann Geier ensured no policy or task was overlooked. The time saved by enlisting the help of Ann allowed us to focus on the many other details involved when opening a new ASC.”

Because it is easy for centers to become complacent and allow things to drop off, especially as new people come on board, Carolina Coast anticipates utilizing Ms. Geier again to assess readiness and identify adjustments needed to stay current. This will help keep employees and processes in check, and ensure the continued provision of quality care. “Ann’s stellar reputation and many years of ASC experience are what led us to her, and we could not be more pleased with our decision.”

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