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5 Tips to Ace a Surgery Center Accreditation

The surgery center accreditation process, no matter the surveying body, can be convoluted and stressful.

Here, industry experts suggest five tips for ASCs to prepare and execute for a successful accreditation survey.

1. Present the most current standards handbook upfront. Sandy Berreth is the administrator of Brainerd Lakes Surgery Center in Baxter, Minn., and a surveyor for the AAAHC. She said she is always surprised by the number of surgery center administrators who don't own the current standards handbook for their accrediting body.

"If your accreditation is for 2011, you're going to be accredited with the 2011 standards, not the 2009 or 2008 standards," she said. Prepping for accreditation now means purchasing the most recent standards handbook. While the majority of standards do not change from year to year, small changes can make the difference between a positive and negative outcome for a surveyed center. For instance, between 2008 and 2009, the AAAHC added a chapter on infection control standards to its handbook.

When she walks into a center to start a survey, Ms. Berreth said, she usually said upfront, "Why don't you grab your handbook so that when we discuss standards, and we'll be able to refer to your book?" If the surgery center administrator returns with a standards book that is two or three years old, that sets off a red flag in her mind. Make sure you have a copy of the most current standards handbook easily accessible in your surgery center so you're prepared to answer any questions about compliance when the time comes.

2. Prepare for challenging aspects. Applicants seem to struggle the most with the quality improvement standards and differentiating between activities and studies, though both have separate AAAHC requirements, said Mary Wei, the assistant director of accreditation services at the Accreditation Association for Ambulatory Health Care in Skokie, Ill.

A quality improvement activity involves looking at a center's processes for indicators, such as internal or external benchmarking or links between a peer review and risk management. A study is a written compilation of a center's activities that is determined with a specific goal in mind.

"In order to have a study," Ms. Berreth said, "we have to compile our activities and ascertain what they mean to us. Studies show us how we can improve our activities and what our end result is based on our activities."

To assist in properly meeting quality improvement standards, the accrediting agency has developed a worksheet for applicants to help them review required elements. The sheet walks participants through how to analyze a study individually and see if the surgery center's studies meet AAAHC standards.

3. Set up a space for the surveyor to work. If your survey is scheduled for a specific date — or if you have a 90-day window when you know the survey will occur — you should be able to set aside space for the surveyor to work. "You should always be able to prepare a space that's ready in less than five minutes," Ms. Berreth said.

This could mean the administrator's office or an unused office or empty conference room. The important thing is to make sure the surveyor has access to peace and quiet, as well as several outlets and Internet access. "Expect that your surveyor is going to be on the Internet, and expect that they're going to need to plug in their computer," she said. While free Wi-Fi is not necessarily a "must" for surgery centers, it certainly helps a surveyor feel comfortable.

The surveyor will also need an unused pair of scrubs and a space to change into them to conduct the clinical aspects of the survey. For surgery centers that don't have extra scrubs, she recommends purchasing a pair of extra large scrubs for surveyor use. "Small women can fit into extra large scrubs, but large men can't fit into small scrubs," she said.

4. Document quality and infection control initiatives. According to Healthcare Facilities Accreditation Program standards (along with the standards for other accreditation bodies), every quality-related effort, such as quality improvement projects, must be well-documented and taken to the governing body. Alexa Simkow, director of surgical services at Botsford Hospital in Farmington Hills, Mich., said although ASCs generally do a great job maintaining quality, collecting data and implementing action plans, this detail may be easily overlooked.

"A lot of times, surgery center staff members simply forget to get approval from the governing body [on matters related to quality improvement]," she said. "I think this happens because a lot of times, the physicians are already part of the governing body. When the surgeons are engaged as clinicians and discussing quality during the day, those issues are not always taken back to the governing body."

5. Prepare a list of physicians and staff. Your surveyor will need to see some of your credentialing folders and personnel files, Ms. Berreth said. To make this process easier, prepare a list of all your physicians and a separate list of all your clinical and business office staff. You should also have a list of all contracted services. You can give this list to the surveyor and then provide credentialing information and personnel files based on the employees they select to review. For example, for contracted services, the surveyor may look at your list and then ask to see your laundry contracts specifically.

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