The surgery center must present to the accreditation organization’s inspector the components of an active quality improvement program that is being monitored on a continuous basis; all measurements of data collection & findings must be forwarded to the Governing Body.
How strong is your quality improvement plan/policy and program? Components of an effective program include:
Quality Improvement Studies
Internal & External Benchmarking
Monitoring & Surveillance of the Infection Control Program
Surveillance of the Physical Environment or Environment of Care
Credentialing & Human Resources i.e. Personnel
All aspects need to be documented usually on a quarterly basis or depending on the size and frequency of patient visits. What does your policy say?
Check your accreditation standards manual for guidance as to what they require and implement it into your policy. Get into the habit of creating work sheets and evaluation logs to make your job easier to track the data collection. Remember documentation is crucial for a successful survey.
Here’s to your success,