February 11th, 2018 | Uncategorized

Has this conversation ever occurred in your Office Based Surgery (OBS) or surgery
center (ASC)?

DOCTOR: Good morning, staff. Our accreditation (or re-accreditation) survey is
coming up next week? Are we ready?

STAFF: Yes, Doctor, we are all ready. All i’s are dotted and all t’s are crossed!
We’ll pass with flying colors!

So, how does the Doctor or surgery center Administrator really know that everything is
ready for the accreditation surveyor to come in with white gloves on and check out all
the picky details that we’ve all seen them ask about or pore/pour over? How do you
know that you won’t be blind-sided on survey day?

It’s hard to know that absolutely everything is in place, buttoned up, and in ship shape.
But there are ways to find out just how well prepared your staff and your center is for
survey day. So, here it is, the Pop Quiz of Accreditation! As the physician or surgery
center Administrator, you don’t have time to go through all the details to fully determine
readiness, but you can use this Pop Quiz to get a very good idea of how well prepared
you are for survey day:

5 questions for the surgeon or endoscopist to ask his or her staff to see if they’re ready
for accreditation survey day:

  1. Show me the meds on our crash cart – are they all current? Anything expired?
    Crash cart meds should all be current and NOT expired. The ONLY way to
    know for sure is to have your staff physically show you each of them that
    are on the cart.
  2. Show me the credentials files for the anesthesiologist…… this the current
    anesthesiologist that comes to our center or our office?

    Should the anesthesiologist be responsible for his own credentials? Yes,
    of course, but it’s YOUR responsibility as the Medical Director to insure
    that all licensed independent professionals’ credentials are up to date. It’s
    better to see the credentials with your own eyes than to assume that the
    anesthesiologist has up to date credentials.
  3. Try turning on the AED. Does it work or are the batteries dead?
    We all hope that the AED doesn’t see much use, but when you need it you
    REALLY need it. So, what if the batteries go dead? Whose fault is that?
    It’s YOURS, of course! Like it or not.
  4. Do an unannounced fire drill…….I’m serious…….can you get out the exits or are
    they blocked with boxes of disposables?

    At an opportune time, not too many patients around and NOT on survey
    day, holler to everyone that there’s a fire and we all need to be out of the
    building in 5 minutes. Use your smartphone or watch to time this event to
    see just how long it takes for everyone to be outside and meet you on the
    sidewalk or in the parking lot. Fires and other emergencies happen at
    inopportune times and you and your staff need to be prepared and also
    need to be able to get out of your offices without falling over empty boxes
    or seldom used equipment that lives in your hallways near the exit doors.
  5. Where are the results of our last patient satisfaction survey? How long ago was it
    done? Have they been done at least annually?

    The answer What patient satisfaction survey? is NOT the right answer.
    So, perhaps it’s time to write up your own survey, ask your colleagues
    what type of survey they use, or look online for options from various
    vendors in the patient satisfaction survey business.

Use this Pop Quiz to get you and your staff thinking about the sort of questions that can
come up on survey day and for which you need to be prepared. It’s much better to pass
the survey the first time than to deal with shortcomings and incomplete files later.
Surveys are important tests of your ability to deliver quality care in a safe and infection
free environment. The questions on my Pop Quiz shouldn’t surprise any experienced
physician or staff member. You should be aware of these items and be prepared
because you’re focused on operating a facility that is prepared every day of the week,
not just on survey days.

Need help with any of this? Give us a call at 630.258.2211 or email us at