Accreditation 101

Accreditation 101

Accreditation is a very important facet in ensuring quality in an ambulatory surgery center (ASC). Stephen Kaufman, senior director of the Accreditation Association for Ambulatory Health Care (AAAHC), and Alan Gold, MD, FACS, president of the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) share tried-and-true practices to help make your next survey a success.

Q: What aspects of the ASC model receive the most citations?

A: As contained in the AAAHC Handbook for Ambulatory Health Care, organizations often have difficulty with the standards in Chapter 2: Governance, and Chapter 5: Quality Management and Improvement.

Chapter 2 involves standards that are designed to assure that there is a clear understanding and demonstration of the responsibilities of the governing body. These involve not only the structure and functional relationship of the organization, but also include detail regarding appropriate credentialing. There is a great deal of effort involved.

Chapter 5 addresses peer review, quality improvement studies, and risk management as the three key areas of a quality management and improvement program. The complexities and interrelatedness of the three areas with the need to demonstrate ongoing activity and results makes this a challenging area.

Deficiencies in Chapters 2 and 5 are often reflected in other standards chapters because the areas assessed are critical to the overall function of the organization.
—Kaufman 

A: Since our accreditation standards are provided to the facility prior to the inspection, the ‘deficiencies’ or ‘citations’ we encounter are most often due to misinterpretations or misunderstandings of a particular standard or its intent. For example, a facility might have a complete surgical log book or narcotics record book, but the pages might be removable rather than bound. Certainly, sometimes things may just be overlooked, such as a lapsed license for a per diem employee, or a pathology report missing from a reviewed chart. Many of those issues can be readily corrected, sometimes even during the inspection.
—Gold

Q: What resources do ASCs have available to help them prepare for an accreditation survey?

A: AAAHC has a self-assessment manual which is a valuable tool in preparing for an AAAHC accreditation survey. The manual’s checklist format provides a clear way to illustrate an organization’s current level of compliance with the AAAHC’s standards. Another resource to help prepare for an accreditation survey is to request a consultative survey from the AAAHC. A consultative survey, which is available for a fee, is typically one day in length and is conducted by an AAAHC surveyor. It can be focused on the standards with which the organization feels it needs the most assistance.
—Kaufman 

A: There are many independent accreditation professionals who can guide your ASC through the entire accreditation process, but with the materials provided by AAAASF, it can certainly be readily accomplished by most existing ASC staffs. Besides the accreditation standards manual, we also provide the AAAASF resource guide CD, which includes a variety of reference materials, form samples for the office, operating room, recovery room, and personnel management. These can be used as templates, or may be readily modified and personalized to accommodate the preferences of an individual ASC. OSHA manuals are available online as well, and provide all of the materials necessary to facilitate and ensure compliance with their standards. Finally, the knowledgeable AAAASF office staff is always available as an invaluable resource. 
—Gold 

How Many ASCs Hold Accreditation?

AAAHC: 1,500 ASCs 
AAAHC saw an unprecedented annual increase of 20 percent in its number of accredited outpatient healthcare centers from 2005 to 2006.

AAAASF: 1,100 ASCs 
Through AAAASF’s new subsidiary, Surgical Facilities Resources, facilities in Europe, the Middle East, and South America are now becoming accredited.

Staying a Step Ahead

By Dennis Hursh

Too many facilities work too hard on their quality assurance (QA) plans, by treating them as burdensome ‘paperwork’ which must be manufactured prior to every accreditation survey. Instead, the plan should be treated as an evolving process designed to improve the quality and reputation of the facility. Consider referring to the QA plan throughout the year, having regular brief monthly meetings to discuss quality issues, keeping minutes, and tracking improvements on the issues raised. Keep the surgeons updated on what you are doing — many ‘administrative-phobic’ surgeons are passionate about quality.

Filling out the forms every two or three years to get ready for a survey consumes more time than regular brief meetings. More importantly, keeping the surgeons and staff actively involved in QA throughout the year tends to naturally lead to a true focus on quality that will translate to higher surgeon, staff and patient satisfaction and ultimately, an improved bottom line.

Ironically, many facilities do not work hard enough on their managed care contracts. Too many facilities negotiate the best arrangement possible at the time, and then enter into ‘evergreen’ contracts that automatically renew from year to year. These contracts are then often filed away and forgotten. Instead, the facility should set up a tickler system to review each contract at least nine months before it renews, to determine if the contract still reflects the best possible deal for the facility.

The bargaining position of a successful facility treating many members is significantly different than that of a new facility. Each time a contract is nearing renewal, it should be re-evaluated. Are the fees still reasonable? Have any particular procedures become unprofitable, either because of reimbursement amounts or hassles in getting paid? Small changes in payment or claims handling for a few select procedures can have a major impact on profitability. You don’t know what is possible until you ask.