In a Nov. 12 webinar hosted by the Accreditation Association for Ambulatory Health Care, Ray Grundman, senior direction for external relations, surveyor and past president of AAAHC, presented 10 common mistakes healthcare organizations can avoid when becoming accredited or reaccredited.
According to Mr. Grundman, the most common accreditation deficiencies the AAAHC sees are:
1. Using incorrect version of the accreditation handbook. The AAAHC's accreditation handbook is updated every year. Surveys scheduled before Mar. 1 and performed before June 30 will use the book from the past year, while surveys performed after June 30 use the handbook for the current year. The handbook is available at no cost for accredited organizations.
2. Late application submission for reaccreditation. According to Mr. Grundman, the earlier the application is submitted, the better. Submit as early as six months before accreditation expires. Any later than 2 months before accreditation is cutting it close, he says.
3. Changing survey date after survey is scheduled. After confirmation, changing the survey data may result in late fees or delays.
4. Lack of adequate preparation. Before institutions are accredited or reaccredited, they should determine which chapters are relevant to their accreditation. It is prudent to prepare using the self-assessment worksheets found in the AAAHC handbook; these are the survey forms the surveyors will use on-site. Remember accreditation is a team activity, so all team members should be adequately prepared.
5. Incorrect contact person listed on application forms. The AAAHC communicates vital information through the person listed as the organizational contact. Be sure to keep customer profiles up to date so important communications are not missed.
6. Lack of appropriate orientation for survey team. Think about what the survey team wants and needs to know. Consider what is unique about the organization, what expertise it provides and how staff contribute to the experience of care. Surveyor orientation should include an organizational acclimation process, a clear expectation of the rules of engagement and an area designated for surveyor work.
The following are organization-specific accreditation deficiencies to avoid:
7. Specific survey deficiencies (general). Survey errors found among all organizations include provider privilege discrepancies, performance goal errors, errors in allergy documentation and failure to conduct or document drills.
8. Specific ambulatory surgery center deficiencies. Common ASC survey errors include lack of compliance with CMS requirements, failure to meet fire codes, lack of hyperthermia education, drills and protocols, inappropriate identification of look-alike or sound-alike medications and no lab test authentification form.
9. Specific office-based surgery program deficiencies. On accreditation surveys, common errors for office-based surgery programs include: lack of peer review results, missing written descriptions of quality improvement studies, benchmarking against dissimilar organizations, out-of-date health histories, and provider privilege errors.
10. Specific primary care organization deficiencies. In primary care organizations, survey errors may include failing to demonstrate continuity of care and patient follow-up, failing to incorporate records from other providers into the patient's clinical record, failing to demonstrate medication reconciliation and not having enough space for care activities.
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According to Mr. Grundman, the most common accreditation deficiencies the AAAHC sees are:
1. Using incorrect version of the accreditation handbook. The AAAHC's accreditation handbook is updated every year. Surveys scheduled before Mar. 1 and performed before June 30 will use the book from the past year, while surveys performed after June 30 use the handbook for the current year. The handbook is available at no cost for accredited organizations.
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2. Late application submission for reaccreditation. According to Mr. Grundman, the earlier the application is submitted, the better. Submit as early as six months before accreditation expires. Any later than 2 months before accreditation is cutting it close, he says.
3. Changing survey date after survey is scheduled. After confirmation, changing the survey data may result in late fees or delays.
4. Lack of adequate preparation. Before institutions are accredited or reaccredited, they should determine which chapters are relevant to their accreditation. It is prudent to prepare using the self-assessment worksheets found in the AAAHC handbook; these are the survey forms the surveyors will use on-site. Remember accreditation is a team activity, so all team members should be adequately prepared.
5. Incorrect contact person listed on application forms. The AAAHC communicates vital information through the person listed as the organizational contact. Be sure to keep customer profiles up to date so important communications are not missed.
6. Lack of appropriate orientation for survey team. Think about what the survey team wants and needs to know. Consider what is unique about the organization, what expertise it provides and how staff contribute to the experience of care. Surveyor orientation should include an organizational acclimation process, a clear expectation of the rules of engagement and an area designated for surveyor work.
The following are organization-specific accreditation deficiencies to avoid:
7. Specific survey deficiencies (general). Survey errors found among all organizations include provider privilege discrepancies, performance goal errors, errors in allergy documentation and failure to conduct or document drills.
8. Specific ambulatory surgery center deficiencies. Common ASC survey errors include lack of compliance with CMS requirements, failure to meet fire codes, lack of hyperthermia education, drills and protocols, inappropriate identification of look-alike or sound-alike medications and no lab test authentification form.
9. Specific office-based surgery program deficiencies. On accreditation surveys, common errors for office-based surgery programs include: lack of peer review results, missing written descriptions of quality improvement studies, benchmarking against dissimilar organizations, out-of-date health histories, and provider privilege errors.
10. Specific primary care organization deficiencies. In primary care organizations, survey errors may include failing to demonstrate continuity of care and patient follow-up, failing to incorporate records from other providers into the patient's clinical record, failing to demonstrate medication reconciliation and not having enough space for care activities.
