There are key signage postings surveyors look for upon entering into your surgery center on survey day. These postings should be in a visible area in your lobby/waiting room. You should have postings of Patient Rights and Responsibilities, Notice of Privacy Practices, Advance Directive, Grievance and Ownership Disclosure. Those of you who operate a C-Arm or have any X-ray equipment on site must post notices alerting patients of the risks of such equipment. Some states such as California in reference to the California Medical Board enforce that you need to have visible a sign that states “medical doctors are licensed and regulated by the Medical Board of California” and to include website and phone number. You also need to post a copy of the business license and CLIA waiver (optional, you can post in recovery if you wish). Most of these items are self-explanatory but I would like to provide you with a little more detail here on Advance Directive and Grievance.
Advance Health Care Directives is a set of processes which decisions can be made for a person who for some reason is not currently able to make important health decisions for themselves. This is a legal document that has usually been made with an attorney.
You will need to inform the patient and accompanying witness whether you honor Advance Directives or not. Does your surgery center honor Advance Directives? Whether you do or don’t please remember to make a sign visible for patients to see.
If patients have complaints or concerns in regard to their care it should be encouraged to notify either the medical director, administrator or office manager. There must be a protocol in place to address such grievances. All complaints require administrative follow-up. Patients can either fill out a form the surgery center provides or report directly to the accrediting agency, licensing agency, and the Medicare Ombudsman.
Keep in mind that signage postings are completely different from the actual policy. For example you may have a basic statement in your lobby signage referring to Grievances as ”If patients have complaints or concerns in regard to their care at the surgery center they are encouraged to notify the medical director and fill out a grievance form. Consumer complaints can be made at…” BUT your policy needs to address the following:
●Steps taken to investigate the grievance
●The result of the grievance
●How you will notify the patient
●The time-frame in which the grievance process was completed
Take a moment now to view what postings are in your lobby.
Here’s to your success,
NB