PowerPoint Presentation

[Audio] Linda – Good Evening Everyone - We will start the call in a few minutes; there are participants still joining the call. While we are waiting to get started, please take this opportunity to add any questions that you may have to the chat feed. Also, please enter your name in the chat so that we can capture your attendance to the call. We will try to answer all questions submitted; however, if time does not permit, answers will be provided when the video of this call is posted. If you are calling from a cell phone, please add your name to the chat feed so we can record your participation..

[Audio] (Do Not Forget to Start the Recording) Thank you all for participating in tonight's Quarterly Surveyor Call Here you will see a list of agenda items for this evening. We will begin with some brief announcements and then get into educational content presented by our clinical team..

[Audio] Linda: The first announcement is that Donna Tiberi, survey analyst and member of the clinical team, has retired. Beverly Robins is actively recruiting to fill the survey analyst position that Donna's retirement created. Other newsworthy information is that QUAD A remains front and center with visibility in multiple arenas. We will not go into an in-depth discussion about each activity; however, this slide shows the national associations that we have a presence in, particularly in the non-surgical accreditation programs. Lastly, we recognize the surveyors who conduct the speaking engagements on behalf of QUAD A, Dr. Hillyer and Claudia for the OPT and NARA training and Elsie Crawford and Tawnya Brock for the RHC speaking engagements..

[Audio] Linda Now I'll turn the call over to our clinical team..

Marketing Update. Randi Hamilton. QUADANOW.ORG PATIENTS FIRST. ALWAYS..

Validation Surveys. Resuming October. QUADANOW.ORG PATIENTS FIRST. ALWAYS..

[Audio] As a QUAD A surveyor, your job is to understand the operations of a facility, and through direct observation, document review, and interviews with staff and patient, assess compliance with QUAD A's accreditation standards. Then, you will use the information gathered to complete an accurate statement of deficiency report using the principles of documentation. Of course, your documentation will inform key stakeholders about the corrective actions they must take to submit an acceptable plan of correction. Surveyors must treat all information obtained during the survey as strictly confidential..

[Audio] Although the use of photography during the survey process is not required, QUAD A surveyors may collect photographic evidence to support a finding of noncompliance. We are providing some basic principles to assist you if you do use photographic evidence. QUAD A is responsible for the acquisition, accountability, and security of any photo taken during the onsite survey. The photos must be the sole property of QUAD A; therefore, surveyors should not use their own personal photographic equipment, including cell phones with photographic capabilities..

[Audio] Surveyors may gather photographic photography as a tool, supplementing written documentation, to assure accurate and effective records of observations made during surveys with the intent to produce photographs that are relevant to possible deficiencies. However, without written documentation, photographs cannot stand alone and have little benefit to.

[Audio] Surveyors may use photography as a tool, supplementing written documentation, to assure accurate and effective records of observations made during surveys with the intent to produce photographs that are relevant to possible deficiencies. However, without written documentation of the Who, What, When Where, and How about the issue of noncompliance, photographs cannot stand alone as a statement of deficiency. Photographs may enhance findings of non-compliance by providing visual evidence of noncompliance; however, photographs must not be referenced in any statement of deficiency. With the future enhancement of the surveyor app, there will be a surveyor note section..

[Audio] When taking photographs during a survey, remember the following basic principles: Do not take photos of patients and staff, even if you have their verbal permission; written permission is required. Therefore, avoid taking pictures that will reveal an individual's face or other uniquely identifying information that will interfere with that person's right to privacy. Again, photographs must enhance, not replace written documentation. A surveyor should be able to recall, after referring to your notes, the following information: The object or situation that was being recorded; Facts surrounding the photograph—where the photograph was taken; Who took the photograph; Purpose of the photograph; and Date and time of photograph Do not modify an original photograph; therefore, do not use your personal device to take photographs during the survey..

EXAMPLES OF PHOTOGRAPHIC EVIDENCE. Evidence of improper use or dangerous use of devices Evidence of breaks in sterile field Evidence of safety hazards Evidence of extensive pest infestation Evidence of faulty or dirty equipment Evidence of exit signs Evidence of missing documentation.

[image] Coloured organisers on shelves. Photocopying Facility Documents.

QUAD A Business Associate Agreement Covered Entity Responsibilities -.

NPDB Query. After the organization obtains an initial NPDB query for each practitioner, use of National Practitioner Data Bank's "Continuous Query" (aka Proactive Disclosure Service) is acceptable for the ongoing NPDB information. To demonstrate compliance, the organization would need to have record of a baseline query and then share with the surveyors that no updates have been received from the NPDB. There does not need to be documentation in the record that no further communication has been received. As with any NPDB information, the organization would review the information received (or confirm that no new information had been received) whenever they are granting a new privilege or renewing existing privileges..

Catch all. 3-A-1 AAAASF is committed to establishing minimum guidelines to provide safe and effective outpatient procedure care. The Facility must comply with all applicable Occupational Safety and Health Administration (OSHA), Centers for Disease Control and Prevention (CDC), National Fire Protection Association (NFPA), federal, state and local codes and regulations. The facility must comply with the stricter regulation (whether it is the AAAASF Standard or local, state, or federal law)..

[Audio] Facility 5336. Emergency Preparedness vs. Emergency Training (?).

[Audio] Beth Radzke. Multiple practices located within one facility When to call the clinical team for guidance.

Scoring Guidelines. I think in the old book, where there weren't always options for N/A, surveyors were instructed to mark standards as compliant if they weren't applicable. However, since going live with the portal, surveyors should select the most appropriate score. So, if something isn't applicable, then N/A should be marked. It looks like this may be a hold-over from our paper days! I will let Beverly know so that maybe we can add this item to the next surveyor call..

Receiving Deficiency Reports. Resurveys Health and Safety Immediate jeopardy Extension site additions.

Photocopying documents & Photographs During a Survey.

QUADANOW.ORG PATIENTS FIRST. ALWAYS..

QUADANOW.ORG PATIENTS FIRST. ALWAYS..

[Audio] Linda For the next item on the agenda, we will review the Qualtrics pre-assessment questions and answers. If you have any questions about the slide being discussed, please feel free to ask your question at that time. Please use the raise hand feature and I will call on you..

[Audio] Linda Let's do a Time check! We have time for some questions..

[Audio] Linda Thank you and good night!. QUADANOW.ORG PATIENTS FIRST. ALWAYS..

[Audio] References: Article | Outpatient Surgery Magazine (aorn.org).