Day Stay / Day Surgery

Unsure what standards apply to you?

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Applicable Standards

Applicable Standard(s):

Required: If you hold contracts with insurers such as Southern Cross or NIB for a defined range of procedures you are required to hold Certification to one of the standards. The standard that is applicable to your service is dependent on the type of procedures you undertake, particularly related to the use of anaesthesia and recovery time required. We can help you make this choice.

Choice: You have a choice to use the EQuiP for Day Stay standards. For details about this click here.

General Process:

To view the general audit process please click here

To view the EQuiP accreditation process please click here

Frequently asked questions

Certification

We need a Certification audit. What standards do we need to comply with? How can we get a copy of these?


The first decision is whether you would like to be audited against the Rooms/ Office Based Surgery and Procedures Standard NZS 8165 or the Day-Stay Surgery and Procedures Standard NZS 8164.

To help with this:

The Rooms/Office Based Surgery and Procedures 8165 Standard is for facilities that undertake procedures without the use of sedation i.e. may use local or regional anaesthetic and complete minor procedures.

The Day-Stay Surgery and Procedures 8164 Standard addresses the clinical support necessary when clients are sedated, from minor sedation through to general anaesthesia.

These standards can be obtained from Standards NZ via their website www.standards.govt.nz (select “buy standards” at top of their website page).




How much does a certification audit cost?


The cost is influenced by the standard you've chosen to be audited against and the size of your service. We can provide a proposal to you, which includes the cost information, once we know more about the needs of your organisation.




What documents do the auditors require?


A documentation request letter will be sent pre-audit, as part of stage one of the audit process. Your policy and procedure documents and completed self-assessment are required approximately six weeks prior to the audit date. This is for your first certification audit only and will not be required for subsequent audits.

We also provide a handy checklist which assists you with preparing the documents we need for the first stage of the audit – the document review.




Who are the auditors that come to our facility?


The auditors have a clinical background and competencies within the surgical services area. They are also trained to recognised standards for auditing. They are supported by our office based team and have regular mentoring and other trainings to minimise variance between auditors.

We always endeavour to pick auditors who are based local to your organisation, in order to minimise travel costs, although this is not always possible due to other audit events or mandatory changing of auditors per audit (50% change of audit team per audit).




What happens onsite during an audit?


We will provide you with an itinerary prior to the audit date.

Our auditor will start with a meeting to introduce themselves and plan the day with you. We need to meet with staff, review records, review the environment, follow some of your practices through and talk with some consumers of your service. We will also review some of your management systems.

The clinic needs to be operating on the day of audit.




What happens after the audit date?


A report is prepared and peer reviewed prior to the facility receiving a copy of the draft audit report to check it is factually correct. The facility is also required to plan what actions they will take if any areas of improvement are identified. The auditor(s) will explain this part of the process at the closing meeting at the end of the audit.




Do we receive a certificate? How long is the certification period?


You will receive a certificate that you can proudly display to recognise your achievement.

The certification period is for three years with an interim onsite surveillance audit.





Surveillance

We are considering moving premises next year. What happens in this case as far as certification?


We will need to audit the new premises and can approach this in two ways: attend on site for a couple of hours to review the site against the standards; or often it is possible to tie it into your next certification audit. If you keep in touch with us at the time of the move, our Management team can make this decision in accordance with our regulations as a certifying body.




When and why is a surveillance audit required?


A surveillance audit is always required and is undertaken to ensure the service is maintaining safe practice and to complete an onsite follow up of the progress made against all corrective actions identified at the certification audit.

The surveillance audit occurs at the 18 month midpoint of the Certification period. The audit can be planned two months either side of this midpoint and we will liaise with you to discuss convenient dates.




Who do you require to be present for the Surveillance audit?


The Practice Manager and RN would suffice and access to board meeting and organisation meeting minutes. If the surgeon is on site, the auditor will speak with her/him if needed, but it is not mandatory for them to be on site.




Does a clinic need to be running or is it best on a non-clinic day?


Please ensure regular surgical procedures/surgery or consultations are planned for the day in order that the audit team has the opportunity to speak with the patients using the service.

A clinic day is preferable as patient input is an important part of assessing service delivery.




Have the costs of the surveillance audit already been covered?


Yes, the costs of the surveillance audit are already covered in the proposal and/or the services agreement.





General

How do I engage DAA Group as an auditing provider and arrange for the Certification audit to occur?


We will make it easy for you! The first step is to fill in the 'Request for Proposal' form or to call us on 0508246776. We can send you information with the benefits of selecting DAA Group as your auditing agency. Once we have your information, we will send you a proposal of our costs and breakdown of our services. Then, once you have agreed for us to be your auditing agency, we will begin working with you to find an audit date that will suit you and the auditor/assessor team.




Can you help us prepare/improve our policy and procedure documents?


In the interests of remaining independent we are not able to assist you with improvements of your policy and procedure documents. However, we can provide you with the contact details of consultants who would be happy to assist you with this process.




What is the ruling for Day Stay Certified clinics for cleaning practices? Does it have to be a registered cleaning company or can you have a dedicated staff member for that role?


The standards 6.2.5 and 6.2.6 ask that there is regular and incidental cleaning to ensure a clean environment and good infection control practices. Also that the cleaning agents used are appropriate for the type of areas/equipment being cleaned.

There is no specification to have a professional cleaning company. In our experience, there are usually three ways of managing this:

  • Cleaning company for daily cleaning and waste management
  • Cleaning company for twice yearly cleaning and daily local cleaner
  • Daily local cleaner

Ensure the process put in place takes into account infection control and can provide consistent outcomes.




Our RN is undertaking biopsies - is that in accordance with the standards?


A review of this area is being undertaken by Southern Cross. Please inform the auditors so that they can:

  1. Ensure this information is documented in our reports.
  2. Review what training has been provided to RNs, how competency is being assessed, and what monitoring is occurring.
  3. Encourage the nurse to liaise with their Southern Cross Insurance contract manager as they are interested in this information for their review.
  4. Email the client manager in the office who will notify Southern Cross.





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