6 ASCs that aced accreditation surveys


Here are six ambulatory surgery centers that scored high on their accreditation and certification surveys, with few or no deficiencies cited.  

If you would like to recommend another surgery center for this list, contact Anuja Vaidya at avaidya@beckershealthcare.com.

Aiden Center for Day Surgery (Addison, Ill.). Aiden Center for Day Surgery is managed by Oak Brook Medical Management. The center is accredited by The Joint Commission. This center and Ashton Center for Day Surgery were signed up for initial accreditation, near the time the management company's older center, Oak Brook Surgical Centre, was up for TJC re-accreditation. "Thanks to our long experience with TJC, we were successfully able to replicate our processes, policies, and procedures at our two new centers," says Oak Brook Medical Management compliance officer Alfonso del Granado. All three centers were surveyed back-to-back, three days each. "When the last surveyor, a 15-year veteran, was finished with Aiden, he said we had "raised the bar for ASCs nationwide," he says.

Ashton Center for Day Surgery (Hoffman Estates, Ill.). Ashton Center for Day Surgery, part of the Oak Brook Medical Management network, was surveyed by The Joint Commission. The surgery center team had approximately one month to prepare. "We drilled and drilled and drilled. We performed half a dozen mock inspections, using TJC and CMS surveyor guidelines, and we never cut ourselves any slack," says Oak Brook Medical Management compliance officer Alfonso del Granado. The three centers, surveyed within a nine-day span, had only 17 findings in total. The findings were nearly all documentation-related and quickly resolved.

DISC Sports & Spine Center (Marina del Rey & Newport Beach, Calif.). DISC includes two ASCs, which are accredited by the Accreditation Association for Ambulatory Health Care. The AAAHC survey found no deficiencies in any area of measurement in either facility.

"At DISC, we believe that clinical quality should be based on continuous improvement throughout the organization as an ongoing process, not just a tightening of the belt during inspection time. Every facility should operate at that high standard whether undergoing inspection or not," said Karen Reiter, DISC's COO.

Ms. Reiter also suggests that accreditation-seeking ASCs go through checklists and review questions in advance of the accreditation process. "This reviewing of checklists and mock surveying will help build staff confidence," she says. "Embrace a mantra of continuous improvement and education to optimize the care you are giving to the patient."

The Marina del Rey center features three operating rooms and the Newport Beach center includes two ORs. The ORs are 800 to 1,000 square feet. The surgery centers offer an array of orthopedic and spine procedures, including minimally invasive spine procedures and advanced arthroscopic techniques.

Oak Brook (Ill.) Surgical Centre. Oak Brook Surgical Centre was up for re-accreditation with The Joint Commission. To prepare for the survey, all of the ASC's team from staff to surgeons was involved. After the successful survey, the center continues to run mock accreditation surveys and strive to find ways to improve. "In the end, there is no magic or mystery to acing accreditation surveys. The rules are simple and openly available to anyone. The key is having the will to follow them," says Mr. Granado.

Surgery Center of Des Moines (Iowa) – East. The surgery center completed its CMS survey in 2013 with only two findings and a Joint Commission survey in 2012 with only two findings.

"The Surgery Centers of Des Moines East and West prepare every day for surveys," says Christy Field, RN, quality/risk manager the center. "We have core leadership team actively involved in walking through the facilities and observing for compliance and identifying opportunities for improvement. Teammates are accustomed to being observed and being asked questions as a result of this process. It is a culture we have built over a period of over 10 years and the results have paid off. We are ready for survey every day."

The surgery center also took immediate steps to rectify the findings of the certifying bodies. For example, one of the 2013 CMS survey findings included that the peer review process was completed on some but not all practitioners.

"A new teammate was assigned to oversee the peer review," says Ms. Field. "The process was revised and has been effective. And teammates were provided additional education with return demonstration required on proper use of approved disinfects and monitoring/audits were conducted to assure teammate compliance."

According to Ms. Field, surgery centers aiming to ace their accreditation surveys need active support and buy-in from the ASC leadership. Get out on the floor of the center and in the operating rooms and procedure rooms to observe, she says. It is important for members of management to get involved in the process and provide feedback on their observations.  

The surgery center is the first ASC in the state of Iowa, which opened in 1981. It is managed by Surgical Care Affiliates and includes four operating suites and two procedure rooms. It provides surgical services in a wide array of specialties, including gastroenterology, general surgery, orthopedics, gynecology, plastics, podiatry, ENT and urology.

Surgery Center of Des Moines (Iowa) – West. The ASC completed its CMS survey in April 2014 with only one finding and Joint Commission survey in 2012 with two findings.

In 2012, one of the errors cited by The Joint Commission dealt with documentation, according to Christy Field, RN, quality/risk manager for the center. "Documentation that the facility verified credentialing applicants' ID with a government-issued photo ID was not clear and consistent," she says. "So, a new form was developed and added to the credentialing packet to copy and verify government-issued photo ID. It was also added to the orientation checklist for medical staff and allied health providers."

In addition to rounding by the ASC's core leadership team, the facility prepared for the surveys by networking with other facilities such as those in Surgical Care Affiliates and the Iowa Association of Ambulatory Surgery Centers and learning best practices.

"It is a team effort and our patient and physician satisfaction is very important to us so we strive to continuously improve," she says. "I always tell teammates to take a deep breath and relax; they do a great job every day. A survey is their chance to shine and show off the hard work they do every day and if something is found [that] we need to correct, then we will learn, grow and keep moving forward toward providing the best quality patient care available."

Established in 1983, the surgery center includes 10 surgical suites. Its physicians provide care in numerous specialties, such as ophthalmology, gastroenterology, oral and maxillofacial surgery, ENT, pain management, plastic surgery, podiatry and orthopedics. It is an affiliate of Surgical Care Affiliates.

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