Maintaining Accreditation Status
By Kathy Dix
The environment of care encompasses many facets of an ambulatory surgery center (ASC). Not only does it include the general healthcare environment, but it also includes the physical environment such as patient safety, risk management, facility layout, lighting, privacy, space, and security. Maintaining all of the standards for this nebulous term is often a challenge, simply because it is such a widely reaching sphere. Benchmarking some of its facets can assist in preserving an ASC’s quality, but there are other solutions as well.
James A Yates, MD, president of the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), and founder of the Plastic Surgery Center Ltd. in Camp Hill, Pa., observes that patient safety is one vital element of the whole.
“The key to meeting AAAASF’s Gold Standards of care is to focus on patient safety and an ongoing self-review process using our checklist-formatted standards booklet,” he says. “This applies to creating an operating room (OR) environment that meets strict standards for sterility and safety, including ongoing inspection of equipment, the physical environment, and having emergency protocols in place.
It extends to the recovery room and the presence of qualified personnel trained in advanced cardiac life support (ACLS), as well as a patient discharge system that ensures that every patient who leaves a facility receives safe post-procedure care. Due to growing concerns about anesthesia delivery, facilities applying for AAAASF accreditation must ensure that either a qualified physician, CRNA or an anesthesiology assistant administers anesthesia (under the supervision of a qualified anesthesiologist). And all physicians performing surgery must be board-certified and have hospital privileges. The gold standard of 100 percent compliance and comprehensive standards motivates each facility to confidently prepare and be able to answer “Yes” to all standards that apply to their level of practice before an inspection is scheduled.”
Although the AAAASF does not currently benchmark specific standards, their standards were designed to achieve the highest level of patient care. “Every physician operating in an AAAASF-accredited facility must belong to a peer review group and submit at least six random case reviews and all unanticipated sequelae every six months via our Web site,” Yates adds. “We have extracted data to report a significantly low rate of complications after surgery.”
Because AAAASF standards are provided in a checklist format, and can be used for a self-review before inspection, Yates points out, “There should not be any surprises as far as how to prepare for the actual inspection. Facilities can easily comprehend what is required to meet a specific standard, so deficiencies are few, and easily reconciled within the 30-day period allowed to correct deficiencies.
“Another area that is under constant review, and rightfully so, is medications,” he continues. “A reliable procedure to monitor expiration dates and replacement of required meds is necessary to stay on top of expired meds. A proof of purchase is required to correct any deficiencies that may result in this area.”
Another common problem that affects facilities surveyed by the AAAASF is that they are required to meet requirements from a number of agencies that sometimes appear to be in conflict but, in actuality, are not. These include HIPAA, federal standards, Medicare, the Occupational Safety and Health Administration (OSHA), state and local rules and the National Fire Protection Association (NFPA). “Our response is always that the more stringent requirement does take precedence,” Yates clarifies.
Karen McKellar, BA, has been a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC) for 14 years. McKellar, who has 37 years of experience as an administrator, has also been a member of the accreditation committee at AAAHC for six years. In the ASCs that she surveys, privacy is one of the biggest concerns, she relates. “I seldom see facilities that do not make every effort to provide it, but the facilities that are doing the best job have separate interview rooms for part of the entrance process, and may have bays that provide a little more privacy than a curtain,” she explains. “Most of the facilities we see do a fairly decent job of being cognizant of the patient’s privacy needs.”
Facility layout, too, is rarely an issue, although older facilities may be grandfathered in to a life safety code, as they were constructed before the current guidelines were in effect. “Most facilities we review are doing a good job of managing environmental issues,” she clarifies. “There’s very little infection; facilities are kept clean; they’re using appropriate sterilization and cleaning techniques.”
One item that has changed from older construction is the number of windows in each facility. “There are so many windows that they have to install privacy blinds, to assure that there’s not a way to see in from the outside. Because there’s a patient in there, you need to make sure they can completely close out viewing,” McKellar points out.
Now that many accreditors’ surveys are unannounced — such as the Medicare deemed status survey — there is little “scrambling” at the last minute to ensure that everything in the facility is survey-ready. “I think where you initially saw a difference was, it was all the organization’s choice (when the association first began offering surveys), so if the ASCs were interested in accreditation, they chose to go through the process and were very committed to the standards and to the process themselves,” McKellar relates. “Over the last 26 years, states passed mandatory accreditation for ASCs, so the biggest change was that organizations that were mandated to do this at times were not as conversant with the standards as the ones seeking it on their own. [Those seeking accreditation voluntarily] were more familiar and understood how to apply the standards to their setting.”
Keeping up with standards is made easier by benchmarking — which is now part of the core standards rather than a suggestion. Surveyed facilities are asked if they benchmark to national standards. However, AAAHC does not require that a certain organization’s standards are to be used. “We don’t dictate that everyone has to use the Federated Ambulatory Surgery Association (FASA), for instance. What we’re looking for is that they compare key performance measures with other similar organizations or with recognized best practices. (They need to use national or professional targets or goals.) If, for instance, you wanted to look at the business or management side of the ASC, you might go to the Medical Group Management Association (MGMA) and look at what the average accounts receivable is, or how many claims can be processed by a biller.
They may look at FASA to compare infection rates; they could use AAAHC’s quality improvement arm, because they have done a number of studies. They could use white papers.” Getting the appropriate benchmarking information is the challenge, McKellar points out. “The ASCs ask, ‘How do I get the information? Are we looking at apples and oranges, or are we looking at the same thing?’ As you can imagine, many facilities like to protect their information; they’re willing to share if they can do so as an unnamed source. If I were an ASC with a 5 percent infection rate, for example, I would not want you to know what my name was; I would want to fix it.”
Facilities are also expected to improve over time. “For example, you’d want to see that the infection rate has dropped,” says McKellar. “Let’s say they’re comparing infection rates. We’d like to see that’s they’re dropping or nonexistent.” Some clinical benchmarks include OR turnover time, nursing time per case, or rate of transfer to a hospital or emergency department.
“Sometimes I look at total time per case,” McKellar comments. “If the facility is doing knee arthroscopies, you’d look at one physician that takes an hour and one that takes forty minutes but the outcome is the same. Or you might look at the number of referrals to an ophthalmologist for diabetic patients. If you’re dealing with a large diabetic population in your practice, are you doing foot exams? This could pertain to multi-specialty groups or college health centers or Indian health centers — it has to deal with the patient’s overall health and is therefore a standard of practice.”
Beth Remus, principal of Remus & Associates, Inc., in Chicago, provides consultation services in accreditation, cultural competence, quality improvement, and service design for healthcare organizations.
“The accrediting body will ask you, annually, to show you are compliant with all the standards and to evaluate yourself. When you do that, you are saying certain things are in place,” she explains. “Now, you could misevaluate, or under-interpret, or make an honest human error or mistake — that happens for all of us. At the same time, there are some things that, if you don’t know them, will affect your competency.”
To help a facility prepare, Remus will work directly from the standards and provide a walkthrough to ensure the facility is meeting the accrediting body’s requirements. “The biggest issue is under-interpretation; rarely does someone over-interpret — meaning they’re doing more than is absolutely required.”
And Remus insists that the facilities must know each city, state, or other standard or regulation that they are responsible for, including the fi re marshal’s requirements and those of public health. “You have to be able to blend those two, and frequently, that’s an area of discomfort for facilities. They don’t know exactly what the standards are, or they think they’re two separate things, but more often than not, they’re not separate — they blend pretty well, or they are very concrete. For example, ‘You must have an inspection by the fire marshal.’”
Remus must also consider how well those blend with the accrediting bodies’ standards — what the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) calls ‘performance improvement.’ “A lot of the things in environment of care require inspections or monitoring to make sure they’re safe, to make sure they’re minimizing risk, so the difficulty they have, is understanding how to integrate and synthesize both of those. There should be regular inspections to check that everything is running smoothly, but if it isn’t, where do you go? Does a manager take care of it? In healthcare, they are looking for a flow from the manager or designated person, and how it flows into performance improvement. Where is the committee structure or infrastructure to do that? If you picture a wheel, the middle is environment of care and around it is leadership.”
You must look at the leadership and other aspects such as infection control to see how they might interface, Remus affirms. When she studies a certain chapter of standards, she reads it while keeping in mind the standards of every other chapter, because they must all interface.
“That’s where a lot of facilities fall down,” she says. “They think of them as separate ‘silos,’ that they’re functioning independently. But JCAHO has done a great job in the last number of years of getting rid of duplication in standards and making sure it’s integrated a better way, and that it is cross-referenced. It helps the ASC by giving them a road map.”
“ASCs need to approach the safety of the populations served in the ASC by considering each standard in the context of their population and the services rendered,” she adds.