The accreditation process is a complicated one and one that most ambulatory surgery centers find daunting. According to Sandy Berreth, RN, MS, CASC, administrator of Brainerd Lakes Surgery Center in Baxter, Minn., and surveyor for the Accreditation Association for Ambulatory Health Care, ASCs should put together a dedicated quality and accreditation committee to ensure that the organization earns accreditation and maintains quality thereafter.
Here Ms. Berreth discusses quality and accreditation committees at ASCs — how to put them together as well as mistakes to avoid.
Question: Why is it important for ASCs to put together a quality and accreditation committee?
Sandy Berreth: A committee will show commitment to the process. It would be the expectation that the committee would read, evaluate and assess all of the accreditation information. As this can be a daunting process, having more than one person will make the tasks doable. It is always important for more than one set of eyes to review policies, processes and practice.
Q: What are some of the key considerations ASC administrators should keep in mind when setting up the committee?
SB: First, you must assemble a team that is committed to the job and follow through. Each team member needs to be given autonomy to get the jobs done. Each member needs to be able to work independently. Also, the team members need to like each other and not be easily offended by other members. This is about getting a job done to the best of our abilities.
Q: Who should be on the committee? How do you select these people?
SB: This is an easy one. Whoever is willing and able. Again there needs to be an understanding that this process will take diligence and work to get [the] organization ready and always keep it ready. Although, when beginning the process, to "get" accredited seems difficult, once accomplished it is easily maintained by the quality committee. After all, accreditation is about quality of care and that is the prime objective of the "quality" committee.
Q: What are the members responsible for?
SB: As mentioned previously, it is about the preparation for the journey of accreditation. I personally assign chapters to be prepared and discussed at length. At first meetings will be frequent, once the tasks are established and completed, follow-up will be done. It is only after this process that the organization should make an application. If doing "deemed status" the survey will be unannounced. If doing non-deemed status, the organization will be notified of the time and the surveyors.
Q: What, in your opinion, are some common mistakes to avoid when setting up an accreditation committee?
SB: Firstly, thinking only two or three [people] will be able to accomplish all the tasks. If this is your first time, the organization should have several willing participants. Secondly, not discussing the standards at the committee level for a better understanding.
Q: How soon should ASC administrators begin putting the committee together?
SB: The decision needs to start at the governing board level to decide the three "W's" — Who, When, Why? After the decision is made to proceed, the committee should come together at least a few months prior to application.
Q: What are some of the challenges of setting up an accreditation committee? How can they be overcome?
SB: If you have chosen your team well, there will not be challenges regarding the setup. All the steps need to be discussed before the subcommittees and tasks are established, and if someone doesn't think they can meet the expectations, they will need to be replaced in the committee.
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