ASC Accreditation During The COVID-19 Pandemic
The Texas Ambulatory Surgery Center Society provides members with information and education through bi-weekly virtual town halls. On February 11, members learned what to expect in regards to surveys for accreditation programs during the COVID-19 pandemic.
The Joint Commission’s ASC Business Development Manager Valerie Henry reviewed how her organization has pivoted during the pandemic to continue providing accreditations, such as Medicare certification, granted by the Centers for Medicare and Medicaid Services (CMS). The initial response was to cease surveys for three months to focus on advocacy, resources, process improvements and outreach calls to pending and follow-up surveys. Additionally, there was the launch of a dedicated webpage to COVID-19 resources.
Following the initial three-month public health emergency, Henry discussed certain criteria to determine what facilities were safe to travel to during the pandemic — criteria such as low risk counties with low case numbers, state level restrictions, testing capacity and case trends. One tool used for tracking trending case data is the COVID Community Prevalence Dashboard, which is available to everyone and can be sorted by state and by county.
Henry informed attendees that The Joint Commission is “committed to keeping our surveyors, reviewers and organization safe as we conduct our work”, thereby establishing two options for surveys:
- On-site surveys in low risk counties
- Off-site surveys, if low risk criteria isn’t met
Should an ASC qualify for an on-site review, it can expect safe practices from a surveyor, such as social distancing, PPE, driving separately to locations and use of technology. If appropriate, on-site will always be the first option.
However, if off-site is deemed appropriate by account executives, the only segments it is available to include are:
- Initial Deemed ASC (no CCN assigned)
- Initial Non-Deemed ASC
- Initial and Resurvey Telehealth (non-surgical)
- Initial and Resurvey Sleep Centers (non-HAP based)
- AHC/OBS Early Survey Option
One of the differences that deemed programs can expect is that any off-site visit will be followed by an on-site visit later, to be determined by the account executives and based on safety criteria.
Henry discussed that in order to ensure success of an off-site event, a dry run to test technology is critical. Account executives will reach out to the ASC to discuss what is available in regards to technical equipment, and the ASC will be required to provide uploaded documentation prior and establish if Zoom and webcams are available.
Centers can expect the below documentation to be required for upload prior to events. In fact, Henry shared that these documents may potentially have a continuing indefinite future.
- Organizational Chart
- CLIA Certificate
- Performance Improvement Plan
- Infection Control Plan
- Environment of Care Plan, Initial Testing, Drills
- Emergency Management Plan
- Formulary
- List of Contracted Services
- Patient Care Policies
- Infection Control
- Medication Management
- Waived Testing
- Provision of Care
- Record of Care
- Patient Rights and Responsibility
- NSG
- Culture of Safety and Quality Evaluation Data
While documentation is requested prior to any event, most off-site surveys are still unannounced until the morning of the survey. Centers will be notified through The Joint Commission’s Extranet Secure site with Zoom or online meeting connectivity information. The length of the event is determined by the program or the type. As an example, the first day would be a full day of clinical, and the second day would be a half day of life safety.
Henry confirmed that The Joint Commission was able to catch up from the initial three-month delay. One of the recommendations she makes is ensuring that applications are received four to six months in advance for proper facilitation of events, based on the volume they see.
“We are confident in our virtual survey process. Feedback from surveyors and organizations is that it feels like the normal survey once you get over the fact that it’s virtual,” Henry said.
Download The Joint Commission's AHC Evolving w Care virtual Survey
If you have thoughts on this topic, leave a comment below. If you have questions for the speaker, feel free to reach out:
Valerie Henry
Business Development Manager (Texas Region)
Ambulatory Care Services
Phone: (630) 792-5247
Email: [email protected]
www.jointcommission.org
TASCS is dedicated to providing continuing education, so stay tuned for the next virtual town hall! Additionally, if you have an article you think would benefit the ASC community, email your ideas to [email protected].
