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Accreditation and compliance challenges in the ambulatory surgical centerHelen Starbuck Pashley
AORN Journal Clinical Editor
Virginia McCollum, RN, MSN, accreditation surveyor for The Joint Commission, discussed ambulatory surgical center (ASC) accreditation during an educational session on Monday at AORN’s 57th Congress in Denver. McCollum explained that Mark R. Chassin, 
MD, PPP, MPH, president of the Joint Commission wants to see health care become as safe as the airline industry. To do this, high-reliability organizations with cultures of safety that strive to reduce sentinel events are needed. The Joint Commission, like many organizations has implemented Lean Six Sigma process improvement tools to improve survey process, accreditation, and responses to accredited institutions’ questions. Lean Six Sigma is a rigorous and systematic methodology that uses information and statistical analysis to measure and improve operational performance by identifying and preventing defects, or in the case of health care, sentinel events.
The Joint Commission accreditation process for ASCs has changed in 2010, and now includes unannounced surveys, individual patient tracers to collect data, a survey guide for facilities, a ready-to-go list to help facilities prepare for accreditation, onsite survey activities and education that help surveyors see what employees do best at their facility, and periodic performance review formats. Surveyors have no suggested agendas and base their surveys on the organization being surveyed, tailoring their surveys to observe and investigate what a facility does most frequently or best.
The Joint Commission is focusing on a culture of safety for patients, leaders, staff members, and the environment. Ambulatory surgical centers can be surveyed as either free-standing centers or part of the hospital they operate out of, which according to McCullom will alter what is surveyed although she did not say how it would be altered. Surveyors will want to know the facility’s mission statement, beliefs, and attitudes. New in 2009, The Joint Commission wants to see facility managers define a code of conduct that identifies what constitutes inappropriate behavior. Although they do not expect ASCs to have as elaborate a system for investigating sentinel events as they expect for hospitals, they will want to see that a system to investigate these events is in place and working. For example, surveyors may ask ASC staff members “What would you do if . . . ?” McCollum recommends monitoring sentinel event alerts.
National Patient Safety Goals (NPSGs) have been altered as well. Topics are selected based on evidence that an event negatively affects patient safety, is wide spread, and has developed solutions to address the issue. The NPSGs apply to all accredited programs (although not all NPSGs apply to every facility). All accreditation requirements are reviewed regularly and some have been deleted. Seven out of 17 NPSGs apply to ASCs.
Significant accreditation changes include requiring the timely reporting of incidents; hand hygiene programs have been made more realistic (ie, a program must exist, goals must demonstrate improvement); and health care-associated infections are no longer considered sentinel events because anything that leads to death or significant physical or psychological injury is automatically a sentinel event. In addition, all medications must be labeled on or off the sterile field. As McCullom said, “If it hits the table, it needs a label!” The Joint Commission also is reviewing the Universal Protocol to make it more specific and practical. McCullom encouraged the audience to visit The Joint Commission web site for updates and further specific information.
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