Here are 10 best practices for successful preparation before an accreditation survey.
1. Purchase new accreditation standards every year. Preparing for accreditation will be easiest for centers that stay up-to-date on accreditation standards, whether or not the center will be surveyed that year, says Dawn Q. McLane, regional vice president of operations for Health Inventures. "If you buy the new book every year, even if it's not an accreditation year for you, you won't have to do as much work to go through your survey because you've done the work every year," she says. "If, [instead], you take a break on non-accreditation years, you're going to have to play catch up and do a lot more work."
She recommends buying the standards published by your chosen accreditation body every year and implementing any changes on an ongoing basis. If your center is already compliant with standards by six months before your survey date, you will have a lot less work to do to get ready.
From 8 Ways to Prepare for Accreditation.
2. Draw out preparation in stages. ASCs should strategically plan stages of preparation at different intervals throughout the year leading up to the survey date. This may mean setting goals one year, six months, a month and a day before the scheduled survey. Meeting with your governing board, researching your accreditation organization's standards and start the accreditation application may be some of the goals to achieve one year before the survey. One month before the survey, ASCs might consider getting all documents in order and preparing staff for the surveyor's visit.
From How to Prepare for Accreditation a Year, Six Months, a Month and a Day Before Your Survey.
3. Address risk-management. During an accreditation survey, surveyors are responsible for reviewing and documenting how the organization provides care in a safe and sanitary environment. It is critical for the organization to develop processes to ensure it can provide consistent, high quality care for the various types of procedures it performs. The organization should define their clinical procedures and review or create policies for risk management in their setting. Additionally, organizations should keep current with standards relating to infection prevention.
From 4 Things Every Organization Should Know About Preparing for Accreditation.
4. Annually appoint an "accreditation team leader." This leader's responsibilities would include reviewing standards, keeping up-to-date with industry articles on accreditation and compiling necessary documents in an orderly and surveyor-friendly format, says Joan Dentler, MBA, co-founder of ASC Strategies, an ASC consulting firm. The leader can prepare memos or newsletters providing good accreditation preparation tips and practices to distribute to the staff. This leader can also provide updates to the board of directors and investors about accreditation and safety-related projects that are pending and recently completed, or make proposals about projects, such as new QI studies or training exercises, which the leader feels may help with maintaining accreditation.
From 6 Tips to Become Better Prepared for Unannounced Surveys.
5. Form a diversified committee charged with tackling specific accreditation issues. If a "team leader" approach isn't the best solution, ASCs should consider forming committees of subject-matter staff member experts who actively tackle issues related to accreditation standards. This way an ASC can better position itself for a more successful survey based on a team effort.
"Those committee members take what surveyors are going to look at and roll through each chapter of the accreditation standards, evidencing that we're aligned with those standards," says Jim Stilley, CEO of Northwest Michigan Surgery Center in Traverse City, Mich. "One of the chapters includes information about patient rights, so we want anyone involved in the process of patient intake to be involved in that committee, including the front desk personnel and registration department."
From 6 Steps to Improve Preparation for an Accreditation Survey.
6. Revamp past policies. If at all possible, with permission from the appropriate personnel, surgery centers should use policies and procedures from previous workplaces as a template. By using policies and procedures from her previous hospital employer, Freida Toler, administrator at Amarillo (Texas) Endoscopy Center, saved time and energy needed to build policies from scratch and helped her facility more quickly achieve accreditation by the AAAHC.
"With permission from the hospital where I was the manager of the endoscopy lab, I brought over the policies and procedures that were used there and revamped them to fit the needs of our endoscopy center," Ms. Toler says. "It required some changing because hospitals run in a completely different manner than ASCs."
From 5 Best Practices for Applying for Early Option Accreditation.
7. Consult with other surgery centers. In addition to adopting past policies and procedures from her previous place of work, Ms. Toler also consulted with another ASC manager of a surgery center in Wichita Falls, Texas, who assisted her in building up a set of policies and procedures that would help the facility achieve accreditation.
"A Wichita Falls ASC manager took the policies used at her facility and shared them with me so I could better adopt different ideas to Amarillo," she says. "Sometimes in the medical world, people are willing to help each other. Maybe it makes a difference that she was a long ways away from me so she wasn't in the same competing market, but even the local hospital here and I are not opposed to calling each other and asking questions. We don't feel the need to always be such cut-throat competition."
From 5 Best Practices for Applying for Early Option Accreditation.
8. Stay up-to-date on changes in accreditation standards. ASCs sometimes struggle with keeping apprised of changes to accreditation standards as a result of Medicare rulings, so when it comes time for an accreditation survey, ASCs may be caught off-guard by new regulations they did not know were implemented. In order to overcome this challenge, ASCs must work even harder to ensure they are updated on the most recent set of accreditation standards. This can be accomplished by going to the Medicare website regularly, attending meetings held by accrediting bodies and hiring consultants.
From 4 Best Practices for Keeping Up With New Accreditation Standards.
9. Focus on infection control. Infection control has become one of the recent hot button issues in the ASC industry. As a result in the changes in the conditions of coverage by CMS in 2009, ASCs are now faced with the new struggle of strengthening infection control programs at their facilities. This can be achieved in a variety of ways. One such best practice ASCs should adopt when looking to implement a new or strengthen an already existing infection control program is audit physicians and staff members on compliance. By auditing physicians and staff members on how compliant they are to hand hygiene, ASCs can make better-informed decisions on how to carry out new protocols and regulations.
From Case Study: 6 Practices for Improved Infection Control at Central Illinois Endoscopy Center.
10. Revisit your quality improvement program. Implementing an effective quality improvement program is not only essential to achieving accreditation by the Accreditation Association of Ambulatory Health Care but also can put surgery centers on the road toward improved patient safety and clinical outcomes. As a result, ASCs should revisit the process and procedures around its QI programs to ensure it is effective in measuring outcomes and highlighting areas of improvement.
From 3 Easy Steps to a More Effective Quality Improvement Program.
1. Purchase new accreditation standards every year. Preparing for accreditation will be easiest for centers that stay up-to-date on accreditation standards, whether or not the center will be surveyed that year, says Dawn Q. McLane, regional vice president of operations for Health Inventures. "If you buy the new book every year, even if it's not an accreditation year for you, you won't have to do as much work to go through your survey because you've done the work every year," she says. "If, [instead], you take a break on non-accreditation years, you're going to have to play catch up and do a lot more work."
She recommends buying the standards published by your chosen accreditation body every year and implementing any changes on an ongoing basis. If your center is already compliant with standards by six months before your survey date, you will have a lot less work to do to get ready.
From 8 Ways to Prepare for Accreditation.
2. Draw out preparation in stages. ASCs should strategically plan stages of preparation at different intervals throughout the year leading up to the survey date. This may mean setting goals one year, six months, a month and a day before the scheduled survey. Meeting with your governing board, researching your accreditation organization's standards and start the accreditation application may be some of the goals to achieve one year before the survey. One month before the survey, ASCs might consider getting all documents in order and preparing staff for the surveyor's visit.
From How to Prepare for Accreditation a Year, Six Months, a Month and a Day Before Your Survey.
3. Address risk-management. During an accreditation survey, surveyors are responsible for reviewing and documenting how the organization provides care in a safe and sanitary environment. It is critical for the organization to develop processes to ensure it can provide consistent, high quality care for the various types of procedures it performs. The organization should define their clinical procedures and review or create policies for risk management in their setting. Additionally, organizations should keep current with standards relating to infection prevention.
From 4 Things Every Organization Should Know About Preparing for Accreditation.
4. Annually appoint an "accreditation team leader." This leader's responsibilities would include reviewing standards, keeping up-to-date with industry articles on accreditation and compiling necessary documents in an orderly and surveyor-friendly format, says Joan Dentler, MBA, co-founder of ASC Strategies, an ASC consulting firm. The leader can prepare memos or newsletters providing good accreditation preparation tips and practices to distribute to the staff. This leader can also provide updates to the board of directors and investors about accreditation and safety-related projects that are pending and recently completed, or make proposals about projects, such as new QI studies or training exercises, which the leader feels may help with maintaining accreditation.
From 6 Tips to Become Better Prepared for Unannounced Surveys.
5. Form a diversified committee charged with tackling specific accreditation issues. If a "team leader" approach isn't the best solution, ASCs should consider forming committees of subject-matter staff member experts who actively tackle issues related to accreditation standards. This way an ASC can better position itself for a more successful survey based on a team effort.
"Those committee members take what surveyors are going to look at and roll through each chapter of the accreditation standards, evidencing that we're aligned with those standards," says Jim Stilley, CEO of Northwest Michigan Surgery Center in Traverse City, Mich. "One of the chapters includes information about patient rights, so we want anyone involved in the process of patient intake to be involved in that committee, including the front desk personnel and registration department."
From 6 Steps to Improve Preparation for an Accreditation Survey.
6. Revamp past policies. If at all possible, with permission from the appropriate personnel, surgery centers should use policies and procedures from previous workplaces as a template. By using policies and procedures from her previous hospital employer, Freida Toler, administrator at Amarillo (Texas) Endoscopy Center, saved time and energy needed to build policies from scratch and helped her facility more quickly achieve accreditation by the AAAHC.
"With permission from the hospital where I was the manager of the endoscopy lab, I brought over the policies and procedures that were used there and revamped them to fit the needs of our endoscopy center," Ms. Toler says. "It required some changing because hospitals run in a completely different manner than ASCs."
From 5 Best Practices for Applying for Early Option Accreditation.
7. Consult with other surgery centers. In addition to adopting past policies and procedures from her previous place of work, Ms. Toler also consulted with another ASC manager of a surgery center in Wichita Falls, Texas, who assisted her in building up a set of policies and procedures that would help the facility achieve accreditation.
"A Wichita Falls ASC manager took the policies used at her facility and shared them with me so I could better adopt different ideas to Amarillo," she says. "Sometimes in the medical world, people are willing to help each other. Maybe it makes a difference that she was a long ways away from me so she wasn't in the same competing market, but even the local hospital here and I are not opposed to calling each other and asking questions. We don't feel the need to always be such cut-throat competition."
From 5 Best Practices for Applying for Early Option Accreditation.
8. Stay up-to-date on changes in accreditation standards. ASCs sometimes struggle with keeping apprised of changes to accreditation standards as a result of Medicare rulings, so when it comes time for an accreditation survey, ASCs may be caught off-guard by new regulations they did not know were implemented. In order to overcome this challenge, ASCs must work even harder to ensure they are updated on the most recent set of accreditation standards. This can be accomplished by going to the Medicare website regularly, attending meetings held by accrediting bodies and hiring consultants.
From 4 Best Practices for Keeping Up With New Accreditation Standards.
9. Focus on infection control. Infection control has become one of the recent hot button issues in the ASC industry. As a result in the changes in the conditions of coverage by CMS in 2009, ASCs are now faced with the new struggle of strengthening infection control programs at their facilities. This can be achieved in a variety of ways. One such best practice ASCs should adopt when looking to implement a new or strengthen an already existing infection control program is audit physicians and staff members on compliance. By auditing physicians and staff members on how compliant they are to hand hygiene, ASCs can make better-informed decisions on how to carry out new protocols and regulations.
From Case Study: 6 Practices for Improved Infection Control at Central Illinois Endoscopy Center.
10. Revisit your quality improvement program. Implementing an effective quality improvement program is not only essential to achieving accreditation by the Accreditation Association of Ambulatory Health Care but also can put surgery centers on the road toward improved patient safety and clinical outcomes. As a result, ASCs should revisit the process and procedures around its QI programs to ensure it is effective in measuring outcomes and highlighting areas of improvement.
From 3 Easy Steps to a More Effective Quality Improvement Program.