Staying audit-ready: Best practices for Joint Commission Accreditation in ASCs

ASCs often seek Joint Commission^[1] accreditation to demonstrate their commitment to patient safety and quality care. Earning ambulatory care accreditation builds credibility among patients, payers and network providers and reinforces a culture where continuous quality improvement of day-to-day operations is a top priority.

Through its extensive interactions with customers nationwide, Olympus identified key best practices that ASCs have employed when preparing for a Joint Commission audit, as well as potential challenges.

To learn more, Becker’s ASC Review recently spoke with Melinda Benedict, Director of Infection Prevention & Control at Olympus.

The importance of Joint Commission accreditation

While accreditation takes time and money, it demonstrates an ASC’s dedication to patient safety and quality care. The comprehensive operational policies and procedures required for Joint Commission accreditation help prevent healthcare-associated infections, reduce the risk of bloodborne pathogen exposure and help ensure that medical device reprocessing and sterile processing are done safely and effectively.

Accreditation differentiates ASCs in the eyes of patients and payers because this designation is associated with a high standard of care and better outcomes^[2].

“When patients see that an ASC is accredited, it means something,” Ms. Benedict said. “Consumers are getting more savvy about their health. If you are in an area with a lot of competitive facilities including hospitals, accreditation can help level the playing field for an ASC.”

Preparing for an audit: Policies, guidelines and documentation

It’s essential to keep all facility standard operating procedures (SOPs) up to date and easily accessible for staff. When it comes to endoscopes, policies should cover the entire reprocessing cycle, including:

Pre-cleaning
Transport
Manual cleaning
Sterilization
Drying and storage practices
Staff training and competency
Documentation

Understanding established guidelines and integrating them with internal policies helps providers align with industry best practices. Examples of these guidelines include the Association for the Advancement of Medical Instrumentation (AAMI), the Society of Gastroenterology Nurses and Associates (SGNA), the Association of Perioperative Registered Nurses (AORN) and the Centers for Disease Control and Prevention (CDC).

“I think a key consideration with endoscope reprocessing, especially for ASCs that are just starting out and don’t yet have tenured staff, is how to build best practice guidelines into internal policies,” Ms. Benedict said. “That’s where cross-referencing guidelines and standards becomes important – so facilities can integrate that information into their procedures.”

It’s important to thoroughly document all relevant procedure and reprocessing activities, so it’s possible for an auditor to “trace an endoscope” by serial number all the way from the start of a procedure through reprocessing and its placement back in storage. The data that should be documented to support traceability may include the patient ID, physician ID, procedure date and time, reprocessing technician’s ID, reprocessing logs, automated endoscope reprocessor serial number, scope serial number and chemical lot numbers. Ms. Benedict added that traceability can be a valuable tool in audits, as it helps uncover potential gaps that may exist in a workflow process and documentation.

Using reprocessing equipment that automatically records data can make the documentation process easier to manage. For example, the OER-Elite™ Endoscope Reprocessor^[3] maintains records for every scope that is reprocessed. It also records detergent and disinfectant replacements, as well as filter changes. Data can be exported from the reprocessor for easy analysis and viewing if the Joint Commission auditor requests records.

Adherence to internal infection prevention protocols is also critical. These may include rules on hand hygiene, PPE adherence, standard practices for handling biohazard waste and more.

Preparing for a Joint Commission audit

Documentation and traceability are often challenging areas for ASCs during a Joint Commission audit. Missing or outdated documentation is problematic. Examples include incomplete reprocessing logs or serial numbers that have not been recorded. Facilities should also keep instructions for use (IFUs), SOPs and other important reprocessing documents readily available.

“You don’t want to be in a panic trying to ‘fix’ everything the moment that you learn that the Joint Commission is in the area,” Ms. Benedict advised. “In addition, if you just try to put a band-aid over things to pass the inspection, your facility isn’t getting the true benefit of the accreditation process, which is improved patient safety and a mindset of continuous improvement.”

To address these challenges, it can be helpful for an ASC to designate a person or a team as responsible for keeping the organization in a continuous audit-ready state. One effective strategy to prepare for a Joint Commission visit is to perform periodic surprise internal self-audits. This is a way to proactively identify potential problem areas and resolve them.

“It’s so much easier if you have someone who is on top of audit readiness all year round,” Ms. Benedict said. “Not only does it make the inspection easier, but it also encourages the facility to utilize the Joint Commission audit process in the way it’s intended, which is for continuous improvement.”

Establishing audit-compliant reprocessing rooms

In ASCs, the space available for endoscope reprocessing rooms is often limited. Even small reprocessing rooms, however, can still be compliant with Joint Commission audit requirements. One of the most important things to consider is whether the reprocessing area will allow staff to comply with the processes outlined in the manufacturer IFUs.

“When the IFU outlines a required step, it has been validated and should be followed. If adhering to the instructions isn’t feasible, it’s important to find an appropriate solution,” Ms. Benedict said.

Incorporating an appropriate standard or guideline for endoscope reprocessing (e.g., AAMI, SGNA, AORN, CDC, etc.) provides additional guidance, over and above what’s contained in the device IFUs. Examples include staff training and competency recommendations, ergonomics, ensuring the appropriate unidirectional flow of devices during reprocessing and logistical considerations for reprocessing spaces.

Tips for maintaining continuous audit readiness

One thing to keep in mind is that Joint Commission inspectors often hold a pre-meeting with staff who will be assisting with the audit. This provides an opportunity to ask questions before they get started. Typically, there is also potential for an exit interview at the conclusion of the audit to discuss any of the findings and question their findings as needed. If an organization disagrees, they should provide clarification and supporting evidence, such as IFUs, official communications from the manufacturer like field corrective actions, or standards and guidelines, according to Ms. Benedict.

If the findings are upheld even after discussing them with the inspectors, follow The Joint Commission’s established escalation process. This may offer additional opportunities to provide more in-depth evidence of your organization’s compliance.

Ideally, ASCs should adopt a proactive stance toward being audit ready. This means following processes consistently and ensuring documentation is complete and easy to find. As guidelines change, these should be incorporated into internal policies and procedures.

It’s also essential to stay current on employee education. For ASCs with an Olympus service contract, Endoscopy Support Specialist team members are available to come onsite to train staff on how to reprocess scopes in accordance with Olympus IFUs.

“The Endoscopy Support Specialists can come in, look at what you’re currently doing and identify areas for improvement,” Ms. Benedict said. “You can use that experience to help make sure you’re adherent to the IFUs, which is something that Joint Commission inspectors are looking for.”

Olympus’ professional education website^[4] offers webinars on reprocessing and infection prevention, and many of these sessions give participants continuing education credits. Additionally, educational resources specific to infection prevention and control in endoscope processing are available in multiple languages on Olympus’ global Infection Prevention and Control webpage^[5].

ASCs have a proven track record of providing excellent patient care and outcomes at a lower cost than other healthcare facilities^[6], and Joint Commission accreditation is one way to formally recognize an ASC’s focus on quality and patient safety.

“At its core, accreditation is about patient safety,” Ms. Benedict said. “You invest in an audit to help ensure your organization is adhering to, or exceeding, current best practices in your clinical area of expertise, confirming that you meet the same high standards as other accredited ASCs.”

[1] https://www.jointcommission.org/what-we-offer/accreditation/

[2] https://manual.jointcommission.org/Accreditation/WebHome