Audits are necessary to ensure compliance in the ambulatory surgery center (ASC) environment. Still, their benefits can go far beyond compliance, pushing your entire organization to elevate service and improve performance. For example, an ASC audit can help you prepare for an accreditation survey, enhance risk detection, strengthen patient safety, and even protect the financial bottom line.
But there’s both an art and a science to conducting an effective audit. With this in mind, let’s explore how ASCs can conduct audits, which areas they should focus on, common pitfalls to avoid, and a few strategies to strengthen compliance and drive performance improvement.
The key to conducting an effective ASC audit is setting up a framework for success. This starts by outlining the most important areas to focus on, not just for compliance but also for performance improvement. Here are a few crucial areas of focus:
Missing, incomplete, or inaccurate clinical documentation can directly affect patient safety and health outcomes and, as such, is a critical focus area for ASC surveys and healthcare compliance audits. Clinical documentation should provide a detailed record of patient care, including each patient’s medical history and treatment plans, as well as any notes from surgeons or physicians who have seen the patient.
ASCs should ensure that all clinical documentation is up-to-date and as complete and comprehensive as possible. Doing so can help streamline the audit process, support compliance documentation requirements, and ensure accurate billing and coding. Audit insights can also feed directly into clinical documentation improvement programs.
Documentation extends beyond clinical documentation. ASCs should aim to document as much as possible to provide evidence of compliance to surveyors. This includes documenting policies related to patient safety, workflow procedures, patient and staffing communication, operational data, performance improvement projects, and more.
When your ASC has robust records, surveyors and auditors can spend less time collecting the data they need and more time evaluating performance and compliance. However, recording data is only half the battle; ASCs must also strive to store and organize data in a way that is easy to navigate and accurate.
Billing should be subject to careful scrutiny to ensure that all services are billed properly and that coding is accurate. ASCs need to make sure they keep robust revenue cycle records. This includes surgical notes that dictate what coders input to ensure that coding is aligned.
That said, compliance is only part of the reason why billing is an important area for auditing. In addition, ASCs can gain valuable information related to their financial performance when evaluating billing and coding. You may be able to identify gaps in billing or pinpoint reasons for common denials when reviewing this financial data, creating opportunities for improvement and new efficiencies that can help streamline the revenue cycle.
One of the main focuses of an ASC audit is ensuring operational safety. For example, infection control programs must be properly documented, and all staff must be trained on safety protocols. This may include recording any assessments or audits to measure compliance and staff training.
Operational safety encompasses everything from ensuring that enough smoke detectors are installed and maintained within the facility to maintaining quality-control logs for equipment to ensure patient safety. The more you can document here, the better. Documentation should be kept near the equipment or easily accessible online, so staff and surveyors can access the information when needed.
Staffing and credentialing documentation is another area of focus, especially for accreditation. This ensures that your patients are treated by staff who are competent and adequately trained in their specialties, providing a layer of credibility, trust, and safety.
Surveyors will often ensure that all licenses and permits for ASC staff are current and that ASC leaders and administrators are qualified for their positions. All credentialing activities must also be up to date and documented thoroughly.
One simple oversight can derail an entire inspection, leading to unnecessary delays and, in the worst cases, even punitive action. Below are some common errors ASCs should avoid:
Treating an ASC compliance survey as a one-time-only obligation. Your organization should always be survey ready. A common mistake is only preparing for a survey when you know one’s coming, such as for accreditation, but audits can happen when you least expect them. As such, bake compliance into the organization's culture to ensure your ASC is prepared and strive to continuously improve patient safety daily.
Overlooking payer-specific requirements. CMS-certified ASCs may primarily focus on adhering to CMS codes and, as a result, overlook commercial payer requirements. Avoid this mistake by validating procedures against both CMS and individual commercial payer policies early and keeping an exhaustive, up-to-date list of codes and modifiers for each payer. Staff should also be regularly trained on requirements to ensure continuous compliance.
Inconsistent documentation. As mentioned, documentation is a major focus of audits, but also one of the most challenging to get right. Inconsistent documentation, such as incomplete reprocessing logs, missing or outdated serial numbers, or missing or outdated patient safety documentation, can tie up audits and lead to compounding problems. Take a proactive approach to documentation to ensure every process is consistently recorded and readily available for reporting.
Not following through to correct issues uncovered. Whether you’ve passed or failed an audit, there’s always room for improvement, but unless you make an action plan, it’s easy to let those opportunities go. After an audit, prioritize which issues must be fixed and the actions required to fix them. Then, create a timeline and assign owners to each task. This can help create accountability and ensure continuous improvement.
Knowing what to focus on and what to avoid is important, but you also need to prepare your organization with the tools and techniques for success. Here are some best practices that can help strengthen an ASC to be audit-ready:
Develop and follow a structured audit plan. When it comes to compliance, structure is your friend. Research and gather all compliance requirements in one place, then create an audit plan to address each requirement. This may include organizing the plan by focus area, assigning department owners and individual task owners, and highlighting which tasks must be performed and monitored continuously. A structured audit plan can lay the foundation for success and make it easier to track and report performance metrics.
Use checklists and standardized tools. Developing an audit or compliance checklist can serve as a top-level reminder of what needs to be done and help visualize progress at a glance. You can use compliance software, such as SIS Comply, to set up automated checklists to track all compliance-related requirements and establish performance standards the team can aim to meet.
Engage cross-functional teams. Compliance is an organization-wide goal. Every department, from coders and billers to the surgeons themselves, must be accountable and engaged to stay survey-ready. Discuss compliance with the organization's leaders and identify the owners of compliance for each team. Where needed, encourage cross-functional collaboration to ensure quality standards are met, such as informing surgeons what they need to record to inform more accurate coding.
Take corrective actions and measure improvements. As mentioned, it is important to follow through on the results of an audit or mock survey to ensure issues are corrected. Identify the actions that must be taken and assign a task owner to correct the issues. For performance metrics, set goals to improve quality standards where necessary and measure results on an ongoing basis to ensure improvement over time.
Schedule mock surveys (internal and externally performed) to simulate accreditor expectations. Practice makes perfect. Internal mock surveys and audits can help prepare your ASC for the real thing. For extra hardening, use an independent third-party that can be more objective and exacting. They can help comprehensively measure everything you need to watch out for from a real audit or accreditation survey, so when the real thing comes around, you know exactly what to expect.
Once an ASC audit is complete, whether it’s a mock survey or a real one, there’s an opportunity to turn the insights gleaned into actionable initiatives that can improve patient safety and enhance the quality of care services your ASC delivers. These initiatives must be designed thoughtfully and proactively, starting with policy.
First, identify the gaps in your ASC compliance efforts. Where are compliance rates low? Where did the organization fall short in terms of quality? Where can improvements be made to meet industry standards?
Once these gaps have been identified and areas of opportunity have been highlighted, update policies and procedures accordingly. This will require a team effort to understand what needs to change and how, across departments. Then, it’s time to train staff on these changes. Explain what has changed and why, emphasizing the importance of compliance.
Training programs and management should work together to help cultivate a culture of accountability, as well. When employees understand that adherence to policy can protect patients and ensure the ASC's overall success, they will feel motivated to comply, especially if they see everyone else, including leaders, doing the same.
Don’t let audits do all the work for you, either. Align the insights from previous healthcare compliance audits with your own quality reporting and benchmarking efforts. As quality measures are met, you’ll know your organization is making progress, and you can tweak your action plan as needed to improve safety and services continually.
Of course, doing all this work can feel overwhelming without the right tools. By leveraging technology such as advanced electronic health records and compliance software, you can bake compliance into clinical workflows and automate tracking and reporting.
For example, with SIS Comply, you can stay on top of complex regulatory and accreditation requirements with intuitive tools built specifically for ASCs. This includes customizable program documentation and performance tracking, infection-control surveillance and monitoring, task-management checklists for tracking daily, weekly, or monthly deadlines, digital logbooks with automatic time and user stamps, and more.
Auditing is a necessary part of ASC compliance; however, it doesn’t have to be a tedious hurdle. By following best practices, avoiding common missteps, and streamlining the process, an ASC audit can turn from a headache into a strategic advantage that drives performance improvements.
That said, achieving this requires a proactive mindset and a thoughtful implementation. Take the time to think ahead with in-depth audit planning and consider what technology can help you collect and organize data, track performance, interpret results, and guide your next steps.
Don’t wait for surveyors to find the gaps. Take control of your audit process with SIS Comply and keep your ASC inspection-ready.
ASC inspections and audits typically require the following: robust clinical documentation and records that are ready and easy to access, billing and revenue data that reflects accurate coding and billing practices, operational safety workflow documentation that demonstrates a commitment to keeping patients protected from infectious diseases, and the appropriate credentialing data for staff to validate their expertise.
How can technology help ASCs become audit-ready?Compliance software that’s specifically built for ASCs can help you automate credentialing, integrate with regulatory databases, build your own educational documentation and training programs, quickly generate reports for compliance, and more. Digital tools like this can also go a long way toward automating manual processes reporting.
What is a culture of compliance and accountability?A culture of compliance and accountability means policies and practices come first. This is all in an effort to maintain a standard of clinical quality and patient safety. Everyone, from the top of the organization to the lowest level, practices compliance daily and understands that it is their individual responsibility to do their part to protect patients and deliver a high-quality service experience.
How can ASCs assess if they are survey-ready?A great way to assess your audit readiness is to conduct a mock survey. You can design and host your own mock survey or hire an independent third party to conduct the survey. ASCs can also leverage compliance software, like SIS Comply, to implement quality measures and track performance.