How To Pass Every ASC Survey with Flying Colors

By Jennifer Jacobson, RN

What keeps you up at night, health system executives?

If one of your answers is “worrying that our ASC isn’t fully prepared for the next time the surveyor comes knocking,” you’re not alone.

You know that survey duo is coming, but you don’t know precisely when or precisely what they’ll ask to see. And, you’re not 100-percent confident your ambulatory surgery center is ready for such survey scrutiny. One big area of concern: documentation.

It’s Not Easy Being Lean

If you’ve worked in a hospital outpatient surgery department but you’re new to managing an ASC, the “I’m not in Kansas anymore” feeling is an additional survey stressor.

HOPD administrators often benefit from having dedicated support staff and committees who make certain that the facility meets survey requirements and that documentation happens. The HOPD’s survey squad is always ready to present this documentation when the surveyors visit–whether it’s neatly organized in binders or readily accessible on computers.

ASC managers don’t enjoy the luxury of dedicated survey squads. Because an ASC runs leaner than an HOPD, you must rely on staff who are accountable for many other things besides survey readiness. Let’s face it. Amidst the daily ASC hustle and bustle, performing and documenting survey requirements can fall by the wayside.

And there’s a lot to keep track of. As a reminder, surveyors from AAAHC, The Joint Commission, or state regulatory agencies often want to see documentation in one or more of these hot spots:

  • Policies and procedures: Are they up to date? Has your ASC added new policies and procedures that aren’t documented yet?
  • Personnel records: Have you filed each and every identity verification, job description, training record, and performance evaluations? What about certifications and continuing education? Are certification renewals and CEUs on file for every staffer at your ASC?
  • Physician credentialing: Are there expirations that no one has noticed yet?
  • Sterile processing: Do staff understand all of the best practices and manufacturer guidelines? What about staff turnover? Has training for new staff been documented?
  • Infection prevention: Are staff really doing all the things mentioned in the policies and procedures? If not, surveyors will take notice.
  • Emergency preparedness: Your ASC may have done that disaster drill you were supposed to do, but did someone remember to document it?
  • Items many ASCs miss, such as the challenges AAAHC describes here and The Joint Commission lists here.

Surveyors tend to view an ASC more favorably when they see comprehensive, well-organized documentation.

Documentation: Buh-Bye Binders

In an HOPD, you can make due with storing survey documentation in binders. In an ASC, relying on binders is bound to go bad. Binders don’t have built-in tracking. They don’t send reminders and alarms to folks responsible for documenting items. They don’t escalate a missed documentation item to a supervisor who can resolve it.

And, it is a truth universally acknowledged, that ASC staff who borrow the binder and have the best intentions to put it back where it belongs … don’t. That binder is squirreled away somewhere it doesn’t belong, and you will be scurrying around to find it while visiting surveyors wait for you to corral your documentation.

If you want to ensure your ASC is survey-ready 24 hours a day, 7 days a week, 365 days a year, it’s best to ditch the binders and go digital. If setting up the technology you need seems like a Herculean task, you are absolutely correct. But it pays off in the long run when you’re running ASC-lean.

How Your EMR Can Be Your Biggest ASC Survey Superhero

Compass Surgical Partners has carefully selected and customized health information technology (HIT)to store, organize and tag survey documentation at our ASCs. We deploy a range of software solutions, including HST eChart, which is especially tailored for ambulatory surgery centers. And our HIT experts have built the templates necessary to ensure our ASCs are always survey ready.

When survey documentation is digitized, it’s easily searchable. ASC staff can easily pull up answers to any questions surveyors ask. Better yet, HIT helps to ensure that the documentation is there in the first place. It’s like an electronic coach that helps ASC staff take care of–and document–their survey responsibilities.

For example, when it’s time to do that quarterly fire drill to meet NFPA 99 requirements, the software sends an email reminding the person responsible that it is time. The software reminds the person to document that fire drill, and the templates ensure that they document it properly.

Built into our HIT systems is a “variance platform,” which is software-speak for a system that flags less-than-desirable outcomes–like missing survey documentation. If the person responsible fails to conduct that quarterly fire drill, for example, the variance platform alerts a supervisor. And it continues to send alerts higher and higher up the chain of command until that fire drill is completed and documented properly.

Charting a path ‘beyond the binder’ is hard work, but it’s easier when a partner has paved the way by selecting the optimal software, designing the templates, and perfecting the systems that keep your ASC survey-ready at all times.

And the peace of mind that comes with it? Priceless.

Our mission is to create strong partnerships that improve the lives of patients and providers.

Compass Surgical Partners