Three Ways to Avoid Fireworks During Survey

Three Ways to Avoid Fireworks During Survey

Fireworks can be great this time of year, but as a consultant pharmacist, I don’t like to hear fireworks when it comes to surveys.  Some deficiencies are fairly common and avoiding them is not that difficult.  Today we will discuss three of the most common deficiencies in ambulatory surgery centers and ways to avoid them.

Each year the Accreditation Association for Ambulatory Health Care (AAAHC) releases their Quality Roadmap, a report on accreditation survey results. As we analyze the report and compare it to previous versions, one thing becomes apparent…the deficiency categories are pretty consistent from year to year.  The most recent list includes credentialing, privileging, peer review, documentation, quality improvement, infection prevention/safe injection practices and emergency preparedness.

Do some things change?  Sure!  This year with the ongoing COVID-19 pandemic we need to pay additional attention to infection control, safe injection practices and emergency preparedness.  So here are three deficiency areas and some practical tips on avoiding them:

  1. Documentation of allergies: The AAAHC standard states that “The presence or absence of allergies, sensitivities, and other reactions to drugs, materials, food, and environmental factors is recorded in a prominent and consistently defined location in all clinical records.”  Some common citations include allergies with no specific clarification, inconsistent use of “NKA” and “NKDA” as well as inconsistencies between what nursing and anesthesia is documenting.  How can your consultant pharmacist help?  One of the key elements of my facility visits is chart audits.  I spend a significant amount of time reviewing charts for compliance with multiple elements, among them, allergies.  Ensure you have a consistent method for documentation, make it your policy and periodically review compliance.  Your consultant pharmacist should be a key player in making sure you are doing it correctly.
  2. Medication reconciliation: This standard states that each facility “facilitates the provision of high-quality health care by: Performing medication reconciliation.”  Some common citations include medication reconciliation not being performed, not using a consistent form, or documentation does not match what the patient was given on discharge.  How can your consultant pharmacist help?  As mentioned above, chart audits are critically important in determining compliance with this standard.  Your consultant pharmacist should be performing meaningful audits on a regular basis, but I also recommend each facility implement their own audit system to maintain standard requirements. Additionally, determine a consistent way to perform medication reconciliation and provide education to make sure all staff members perform the same task with consistency.
  3. Infection Prevention/Safe Injection Practices:  There are many standards that fall under this umbrella.  This includes items such as how communicable diseases are prevented, identified, and managed; storage and disposal of medications; look-alike-sound-alike as well as high alert medications.  Some common citations include, no evidence of an infection prevention and control program training or competency and not following national guidelines on safe injection practices.  How can your pharmacist help?  This area is so vast, that it would be impossible to cover all the potential ways a pharmacist can help in one paragraph. The services of your pharmacist should extend well beyond checking expiration dates. You should be receiving comprehensive assessment of your medication management to include policy/procedure review, compliance with standards as well as guidance on latest survey findings in the industry.  In my next post, I will discuss the most common safe injection practice citations and many ways your consultant pharmacist can help you improve patient safety and achieve survey success.

Putting these items into action: Here are some steps you can take according to The AAAHC Quality Roadmap:

  • Compare these findings to your last onsite survey report and your annual self-assessment
  • Understand the most common deficiencies relevant to your setting
  • Review policies, procedures, and practices to ensure they reflect best practices and relevant AAAHC Standards
  • Sharing and discussing the findings with others within your organization to drive decision making on Quality Improvement (QI) studies or other corrective actions that may be necessary

As a consultant pharmacist, I have frequent discussions with facilities I serve and colleagues who are surveyors. The one consistent theme in all these discussions is patient safety.  We are all in the business of moving the needle on making the patient experience better and safer.  Facilities are always looking for ways to improve and working with an expert consultant pharmacist can make your patients safer and lead to fewer fireworks during your surveys.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.


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