One of the most important parts of maintaining a surgery center is accreditation. Part of the accreditation process means having inspections.

Inspections can be a stressful time, but there’s no need to try and guess how to prepare! At Custom Surgical Consultants, we help you with everything you’ll need for accreditation. We can even provide you with a mock inspection.

But what goes into an inspection, mock or otherwise? There are key areas to consider. They include: Life Safety, Risk Management, Infection Control, and Quality Improvement. Here’s what you need to know:

Life Safety

When your ASC is reviewed with regards to Life safety, this includes several areas. The inspectors look at how procedures and protocols account for patient safety throughout the facility as well as staff safety.

For example, they will look for written protocols for emergency situations.  This is known as the Emergency Operations Plan (EOP).

The EOP includes:

  • protocols for what to do in case of a security emergency, active shooter, or natural disasters
  • Fire
  • power failure
  • when a surgeon or surgical nurse becomes incapacitated during surgery

It also includes protocols for CPR and how and when to transport a patient to a hospital.

For the facility, it includes maintenance records for the sprinkler systems and fire alarms.

Risk Management

Risk management has many overlaps with the Life safety protocols.  Risk management assessment also includes the safety of materials and information.

Administratively, inspectors look for signage for areas in the center and supply rooms.  This includes protocols for keeping medication and hazardous materials secure.

They’ll check that you maintain a minimum supply of vital drugs and medications. It’s important that medical records are properly stored securely and confidentially.

Many risk management policies and procedures are required to meet the standards.  This is essential for both the safety of patients and the ASC staff.

These procedures should also serve to protect the ASC and health care providers in the case of litigation.

Infection Control

Infection control is an area of concern for every procedure that your ASC performs.  Inspectors will be looking for proper disinfection and sterilization procedures for equipment, patients, and staff.   If there is an infection, they’ll look at how you identify the source of infection and how you evaluate your present infection control process.   An annual infection control risk assessment should be performed.

When considering how well your ASC addresses infection, they may also look at how you’ve handled events in the past.  They’ll also consider how you can improve your protocols in the future.  This is an area that Custom Surgical Consultants can prepare your team.

Quality Improvement

Inspections will be a regular occurrence for any surgical center. Upon each inspection, surveyors will be looking for how you’ve improved.

They will be asking for plans that you have in place to improve the quality of your ASC. These plans should include written and ongoing practiced protocols evaluating the ASC to improve patient care and surgical outcomes.   The quality improvement program should be on-going and regularly collecting data for review.

If you have deficiencies, they should include how you have corrected them in the ASC. They’ll also want to know what mechanisms are in place for communication of information to the Governing Body and back to the staff.

During an inspection, the accreditation organization will be looking for records from peer reviews and at random cases from each surgeon. They will also review every operative sequelae.

In general, inspectors will want to know what plans you have in place for when things go as planned or when things deviate.  They will focus on protocols that will assure a method of continuous improvement.

When our consultants prepare you for inspections, we will help you with each of these areas.

Our consultants will also help you put together procedures for every contingency. This will ensure that you can not only show surveyors that you have plans in place, but you can put them into action. Contact us today if you’re looking for help operating your ASC!

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