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Setting Staff Standards for Office-Based Surgery

Headshot supplied by Rommie Johnson

A plan to manage healthcare staffing changes is more than just a procedural formality. In a small, office-based surgical practice – especially one that has had a stable team for an extended period – creating a structure that brings new staff up to speed is critical to maintaining operational momentum and quality patient care. Accreditation standards for office-based surgery (OBS) provide a framework for organizational excellence. They move a practice from ad hoc organization to intentional anticipation of the changes that come with any business over time.

In OBS settings, an orientation plan with a focus on specific surgical techniques or patient demographics is expected. Beyond that, creating a thorough, documented means to acclimate new employees to your existing practice is simply best practice. By eliminating the need to train policies and procedures on the fly, it reduces stress and establishes benchmarks for professional behavior, patient care, and adherence to regulatory norms, setting the expectation of exemplary care delivery.

An effective orientation plan
 

Accreditation Commission for Health Care’s (ACHC) standards specify the minimum requirements for an orientation plan, and these parallel expectations for annual staff training. In OBS settings, a small team can ensure consistency of practice, but it can also lead to a more casual approach to risk management issues. For this reason, the 10 topics covered in this article are formally delineated as administrative standards.

Collage images sourced from Rawpixel.com

1. Ethics and corporate compliance
 

Corporate compliance means that your organization adheres to legal and regulatory requirements. These are defined by the type of legal entity under which the practice is organized (for example, S-corp, LLC), by the healthcare licensing requirements of the state in which the practice is located, and by the professional standards of practice for the licensed providers working within the organization.

Ethics address the intent to comply not only with the letter of the law, but also with the spirit of the requirements. In other words, a code of ethics sets the expectation that everyone within the organization will do the right thing for the patients they serve. Professional staff policies are expected to include a code of ethics, and staff orientation and training would include distribution and review of these key documents.

2. Patient rights
 

Patient rights are paramount in any healthcare setting, and the expectation of an accrediting organization is that these will be articulated in writing and provided to each patient – either directly or by post. For OBS practices, orientation and annual training must include a review of these rights. The use of role play scenarios can improve understanding of how individual rights are applied in the process of providing care. Examples that could lead to rich discussion include the right to provide informed consent, the right to voice a grievance without fear of reprisal, the right to personal privacy, and the right to receive care in a safe setting.

3. Assessing patient risk for self-harm
 

Awareness that individuals at risk of intentional harm to self or others are treated in all settings is an important element of effective orientation and training. Identifying environmental safety risks for such patients – as well as appropriate actions to mitigate those risks – helps ensure the patient’s aforementioned right to receive care in a safe setting. Building a supportive environment where staff feel equipped and confident to handle such sensitive situations both supports staff retention and manages the inherent risk of these situations.

4. Ensuring patient confidentiality
 

Confidentiality represents both a specific patient right, as well as a legal risk mitigation strategy. New and continuing staff must understand the meaning and scope of protected health information (PHI). It may be appropriate to customize training to various roles, focusing on practical aspects like the secure handling of records and patient information in shared spaces.

Confidentiality agreements for new hires helps reinforce the importance of this issue. As such, you should review and revise your confidentiality policy regularly, using this occasion to conduct refresher sessions during routine staff meetings. This approach ensures compliance without significant resource allocation and means that all staff are up-to-date and suitably informed of any changes to the policy. A culture where confidentiality is a shared responsibility encourages staff to be vigilant and supportive of patient privacy as a collective and prioritized goal.

5. Fire safety and emergency protocols
 

Safety training is critical and doesn’t have to be expensive. Emergency management planning should focus on safeguarding people, maintaining business operations, and protecting physical resources – in that order. Most local fire departments or emergency services will provide training sessions at no charge, and it is wise to take advantage of these free resources.

Beyond fire safety, plan for emergencies with an assessment of the practice’s vulnerability based on likelihood of identified risks (for example, natural disaster, disruption of utilities, public health emergencies, and acts of violence). You can then establish an individual plan for each potential risk and share it with all staff.

6. Handling incapacitated healthcare providers effectively and affordably
 

An incident involving an incapacitated provider can be part of your emergency management plan, and accreditation standards require that it be specifically addressed. Training to recognize and manage an incapacitated colleague can build staff confidence, as well as increase awareness of any potential risks.

7. Quality improvement
 

Implement a data-based, quality improvement strategy that measures performance against identified benchmarks. By consistently measuring your own organization’s performance, you’ll be able see trends and make incremental adjustments for improvement. Beyond orientation and annual training, regular team meetings are an ideal time to discuss and analyze any adverse events or near-misses. Even for a small team, setting aside time for this kind of open dialogue demonstrates that quality is a priority. It leverages collective knowledge and individual points of view, and supports employee satisfaction and retention.

8. Infection prevention and control
 

Your infection control practices are critical, and initial orientation and continuing education on this topic can be managed economically. Again, you can use free resources like the evidence-based guidelines and checklists offered by the Centers for Disease Control and Prevention (CDC).

Encourage a practice-wide culture of cleanliness and accountability, where every team member, regardless of their role, understands and actively participates in maintaining a safe, hygienic environment. This can involve simple steps like regular hand-washing campaigns, proper use and disposal of personal protective equipment, and maintaining cleanliness in all areas of the practice.

9. Hazardous waste management
 

You have sharps and other solid waste; and you may have liquid waste from procedures. Training on medical waste management generally focuses on proper disposal methods. But before planning for disposal, you may want to give some focused attention as to what creates waste in the first place. Take a look at your surgical instrumentation and supplies. Are you using disposables or reprocessing instruments? Are you recycling? Consider a cost/benefit analysis of your options, including the use of solidifying and disinfecting agents for liquid waste. And then you can really train your staff on how to red-bag relevant waste.

10. Communication with outside entities
 

The final required item for orientation relates to contact with external entities seeking information or statements. Expectations around talking to legal or media representatives should be clearly communicated to all staff. Your goal is to foster a professional image for the practice, while at the same time minimizing risk to the organization and its employees.

Time well spent
 

Investing the time to develop a comprehensive orientation plan is a strategic move for the future success of your practice. In terms of compliance and accreditation, practices can integrate accreditation standards into everyday routines, making them a natural part of the work culture. Regular staff meetings and training sessions can be used to discuss and reinforce these standards, ensuring that everyone is consistently aligned with compliance requirements, where applicable. This integrated approach is a cost-effective way to elevate patient care quality and cultivate a culture anchored in safety, compliance, and excellence.

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About the Author
Rommie Johnson

Rommie Johnson, MPH, is associate program director for ambulatory surgery centers and office-based surgery settings at Accreditation Commission for Health Care (ACHC) where he leads a team of talented staff and surveyors. He has worked in health care accreditation for over a decade in diverse roles beginning as a survey report coordinator and progressively advancing with his growing expertise through management and business development roles. He can be reached at [email protected].

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