The Governing Body or Governance assumes full legal responsibility and addresses the operational issues of the facility addressing patient rights, administrative policies & procedures for the effective management of the facility.
This is where it can get confusing but I am going to make this very easy to understand. In earlier postings I mentioned that documentation is everything and it is. To address the operational issues of the facility you must document you are doing so. Whether you are a small facility with 1 (one) member of the GB or a large facility with several members. This is tricky because it can make or break a survey. Documentation will be in the form of minutes. In these minutes you want to provide brief bullet points of items that were presented, reviewed, approved, and monitored by the GB. A portion of those items includes:
Policies and Procedures
Contracts
Fiscal Matters
Quality Improvement Program
Credentialing
If your GB meets annual, semi-annual, or quarterly (check what is in your policy) I highly recommend meeting or documenting meetings more often. Create a four (4) column chart based on the standards chapter (s) you have to meet with your accrediting organization and/or licensing and Medicare deem status. In the first column write the agenda item which is a title of a chapter in your standards manual for instance Facility Environment. Next column you want to headline it with the “discussion.” Simply state if equipment is operational or if there had been preventative maintenance. Third column you want to headline that with “action taken.” Was there any action taken? Were there any repairs needed? Fourth and final column you want to headline “follow-up.” Do you need to follow up with the bio-med company or is it something that needs to be monitored for a few weeks.
The four column chart is an easy documentation tool you can use to show that everything is presented, discussed, reviewed, approved, and being monitored by the governing body.
For more information I am available for consultation and for service if you need assistance on the surgery center re-accreditation/certification process. You can reach me at ABA headquarters. Contact information can be found in the “about me” tab or email me at nb@abmsc.us
Here’s to your success
NB