Administrator’s Corner: Lessons Learned from Accreditation Surveyors

Erica Palmer

Senior Content Marketing Manager

No one understands the struggles and triumphs that ASC leadership experiences like those who have gone through it themselves. We understand Administrators, Business Office Managers, Chief Nursing Officers, Nurses, and everyone else who makes an ASC run successfully because at one point, we were standing right in your shoes.

Welcome to HST’s Administrator’s Corner 👋 Together, we’ll be addressing current issues that ASC leadership are facing to help solve your most pertinent and difficult problems. The advice below is proven and actionable, and we hope you find it helpful!

Question: What was the most important thing you learned from an accreditation survey/surveyor?

Dorothy L. Immel
HST Practice Management Consultant, HST Pathways
Former Regional Business Office Manager and CBO Director in Texas & Oklahoma

Always do it right, and you’ll always be prepared. So often, we see centers frantically scrambling to ensure compliance in the weeks before a scheduled survey. But if you are diligent in maintaining compliance, there is no need for last-minute panic and prep.

If there are deficiencies that you are aware of, make sure that you are addressing them. At one point, the surgery center I worked at became non-compliant on chart completion, but because we had a QI study in place to address this deficiency, we were not “dinged” for it.

Pierre Devaud
Sales & Relationship Manager, Patient Access, HST Pathways
Former ASC admin for 7+ years in New York

In most cases, surveyors are not looking to ding you. Approach the survey with a collaborative attitude where you’re open to learning from the surveyor even if you internally happen to disagree with their findings. I’ve interacted with surveyors in both the acute care and outpatient space. If there is one piece of advice I can share with my administrative colleagues, please review your policy & procedures and look to simplify them as much as possible. Don’t commit your organization to fulfill unnecessarily onerous policies; all this does is provide additional opportunities for the surveyor to identify shortcomings in the fulfillment of your own policies.

Dean Brown
VP of Business Development, HST Pathways
Former ASC Admin for 22 years in Alabama

I have been through five AAAHC accreditation surveys, and it took me two surveys to realize that there is subjectivity in interpreting some of the AAAHC and CMS guidelines. On my 3rd survey, I was very defensive about several issues brought to my attention by the life safety portion of my survey. I think my defensiveness was caused by the fact that other surveyors found no problems in these areas. I was determined to prove him wrong and spent countless hours calling and researching his assessment and confronting him while he was on site. The clinical surveyor could see my exasperation and pulled me aside and said, “you know if you just step back and try to hear where he is coming from and just agree that you can see his points, you will pass your survey.” I changed my approach, listened to his advice, and explained that I could see his perspective. On the final day, all his criticisms were “areas to consider for improvement,” but we did not have to do a plan of correction on any. Sometimes, it is best to listen and not take the surveyor’s findings personally, especially when they do not impact your accreditation or CMS licensure. It is important to remember that the surveyors want to offer advice and assistance on making your center safe and a preferred site for patients.

Kathi Gascho
Senior Quality Assurance Engineer, HST Pathways
Former ASC Director of Nursing in Arizona

I learned an extremely valuable lesson going through numerous past surveys. It is vitally important to follow your own policies and procedures. The “what” of regulation is typically quite clear, but the “how” is often left to the center to determine. I reviewed our own policies and procedures many times to be sure that we outlined procedures that we actually could and did follow and that they were not so detailed as to create no room for necessary variation.