Ambulatory surgery centers (ASCs) rarely welcome the moment a letter arrives announcing an audit, investigation or accreditation survey.
But a strong compliance strategy can make that experience a more positive one.
“In all the years I’ve even worked for a regulator, and all the years I’ve been doing this, I have found very few people, including myself, who can always nail the audit request and really not stress when they get that letter,” Jessica Zeff, CEO of Simply Compliance, said during a recent MedTrainer webinar. “We all get a little bit nervous, and I’m fascinated by this.”
Simply Compliance is a health care compliance consultancy based in Pittsburgh.
“I’ve had clients say to me, well, you know, we can just do this thing we call compliance off the side of our desks,” she said. “No, that’s not going to work.”
Instead, she said, operators should assign a project lead who can coordinate stakeholders, set milestones and ensure responses are timely.
“You treat the audit request as a project,” she said. “Your project lead is going to be controlling those processes and making sure there’s a response to the audit that’s timely.”
One of the most common mistakes centers make is rushing to assemble evidence without explaining what the documentation shows, she said.
“People are so busy trying to pull together evidence and show evidence of compliance, they forget to tell the story of what that evidence is demonstrating,” Zeff said. “Context, context and context – tell that story.”
For example, when auditors ask for compliance training information, screenshots of a slide deck are useless without dates, participation reports and a written policy.
“That literally tells me nothing,” Zeff said.
By contrast, pairing a training policy with a learning management system report showing completion rates, and explaining why a small percentage of staff might have missed training, shows credibility.
And auditors don’t understand a center’s day-to-day operations, Zeff added.
“They don’t know your policies and procedures,” she said. “They don’t know anything about you. In most cases, the documentation you send them is really the first time they may have interacted with you.”
That makes it critical for ASC leaders to connect policies, processes and evidence directly to audit criteria, she added.
Owning compliance gaps, rather than trying to hide them, also strengthens trust.
“If you find that very same risk and you provide a corrective action, that’s then seen as a strong compliance program,” she said.
Finally, she urged ASCs to prepare staff who may be interviewed during audits.
“Confidence can build credibility,” she said. “You don’t want your staff over-explaining or volunteering unnecessary information.”
