With increased scrutiny on ASCs country wide, receiving accreditation is one way to show how standards and compliance are top priorities in our industry. The benefits of accreditation include a higher marketing platform, Medicare reimbursement (in some cases) just to name a few. But which accreditation body should you seek out?
SurgiStrategies spoke with three accreditation bodies — The Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC), and Healthcare Facilities Accreditation Program (HFAP) — to get a closer look at the key components a facility should consider when choosing an accreditor.
Standards
First and foremost, it is important to have a clear understanding of the standards and make sure the facility will be able to comply with them. How are they structured? Are they somewhat vague and left of to interpretation or they very spelled out with great detail? Michael Kulczycki, executive director for the Ambulatory Care Accreditation Program, at the Joint Commission, stresses the important of familiarizing yourself with the framework and language of standards. In the last year, Joint Commission has made a 60-day trial edition of the electronic standards available complimentary to facilities. “For example, many of our standards have a rationale that gives a background on why we are addressing a certain topic. We have icons — (a small D in a circle) — in both the electronic and hard copy manuals that clearly indicate when a requirement needs to be written or documented," he explains. This can be critical because it eliminates potential subjectivity to a surveyors’ preference to see in minutes or policies, but rather, allows organizations to choose various ways to demonstrate compliance. “Many organizations first reaction is, ‘I have to establish hundreds of policies and procedures,’ but the Joint Commission requirements for ASCs that must be written and documented are less then 10 percent," Kulczycki verifies.
“HFAP is not as prescriptive as some others may be but we feel that there are many different types and sizes of facilities and if they can demonstrate compliance in their own way, that’s acceptable," says Troy Ann Repuszka, RN, BScN, deputy director for HFAP. “The HFAP standards are very straightforward and easy to understand. Embedded in the standards are the Medicare Conditions for Coverage along with other quality and patient safety standards. Each standard identifies exactly what the surveyors are looking for which is beneficial for two reasons: there are no surprises, and interpretation of the standard is more consistent."
Raymond E. Grundman, MSN, MPA, senior director of external relations at the AAAHC states that their standards are developed by our Standards and Survey Procedures Committee which is comprised of board members and volunteer surveyors who are all practicing healthcare professionals, who are considered experts in their respective fields. The AAAHC standards are continually reviewed by the committee and updated annually.
“Perhaps as a result of new legislation or more recent studies that affect the current healthcare environment, or simply to acknowledge recent developments in the ambulatory arena," says Grundman. “The proposed changes are posted on our website in August each year for public comment. This means that the revisions do not emanate from just a “brains trust" of AAAHC committee members and surveyors, but are the result of a much broader base of thinking; a consensual change, in fact. Ultimately, this is why we believe our standards are current, relevant and realistic."
