7 tips for ASCs to ace the accreditation puzzle

Ambulatory surgery centers, known for their low infection rates and high-quality care, must earn and keep accreditation to ensure that the standard of care at their facility is top-notch. Accreditation affects both patient volume as well as reimbursement.

Accreditation sets you apart from the rest. It shows both your patients and the public that your center is engaged and offering best practices. Consumers are savvy and will look to see if a site is accredited as that identifies best practices are in place. Another reason for accreditation is fiscal responsibility — insurance contracts typically require that a facility has some type of accepted accreditation, and obtaining and maintaing that accreditation is important to remain fiscally viable with both private and government-funded insurance contracts," says Deb Yoder, MHA, BSN, CNOR, RN, director of clinical services at Surgical Management Professionals.
However, successfully preparing for accreditation surveys and maintaining the certification is one of the most challenging aspects of running an ASC. Here are seven tips:

1. Ensure physicians are credentialed appropriately. The number one accreditation issue for the past 10 years is improper physician credentialing, according to Michael Kulczycki, executive director of the Ambulatory Care Program at The Joint Commission. Mistakes are made either when credentialing a physician for the first time or when physicians are re-credentialed.

"The steps for credentialing are not difficult or complicated," says Mr. Kulczycki. "However, credentialing does include a number of steps. So the real challenge is finding someone who is very detail-and deadline-oriented to be in-charge of credentialing. This process sometimes proves even more challenging for ASCs as their medical staff roster may include 40 or 60 or 80 physicians, which is a lot to track over the years. So it is not surprising that ASCs have trouble with this."

With adequate attention to detail as well as following certain best practices, such as closing all gaps in an application and completing credentialing for new procedures, ASCs can ensure they are staying on top of credentialing.

"Also, having a specific person be in charge of the files, paper or digital, is essential to keeping things organized," says Ms. Yoder "A surveyor doesn't want to muddle through a lot of disorganized paper work, so having folders/tabs organizing the information is imperative. Old data can be stored in a secure area for review if needed. A surveyor told me 'if I can't find it on the first go through, I assume it's not there and move on.' "

Also, as the site grows and new procedures or equipment is added, make sure that information is added to the providers' priviledges and credentials, she notes.

2. Understand the gravity of the accreditation process. Sometimes, ASCs do not take the process seriously and are unprepared, notes Kathleen Bernicky, RN, the director of clinical operations at Regent Surgical Health. Make sure you know your state regulations as well as CMS and accrediting agencies' standards. "Having a complete and accurate set of policies will guide the center," she says.

3. Ask questions and gain information to maintain high-quality care. Read and review information from evidence-based national organizations such as Association of periOperative Registered Nurses and The Association for Professionals in Infection Control and Epidemiology, says Ms. Yoder. The accreditors will look to them for guidance and best practice patterns.

"For example, performing a time-out in the manner laid out by the World Health Organization or AORN aids in best case practice patterns and ensures that the staff are clear on side/site/implants/antibiotics needed," says Ms. Yoder.  

4. Establish a structured program for completing every aspect of the accreditation process. Ms. Bernicky suggests that the program include an ongoing monitoring of a number of areas, such as:

  • Quality Assurance/Performance Improvement
  • Credentialing
  • Infection Control
  • Medication Management
  • Patient Care
  • Staff and LIP education
  • Privacy and Security

Organization is essential, says Ms. Yoder. Keep your minutes and information in a standard binder or location. Keeping it up-to-date after each meeting and project aids in long term time management. Use a template to document all data — easy to fill in and consistent.

Additionally, pay special attention to Life Safety Code requirements. These are becoming more difficult to ascertain and maintain without additional help before a survey, says Ms. Yoder.

"The facility manager needs to be very cognizant of the current building and how it relates to the new standards — especially the HVAC system, temperature and humidity monitoring, fire wall penetrations, generator load tests/remote shut off valves and documentation," she adds.

Another important aspect of accreditation is medication management. Managing high-alert or hazardous medications as well as look-alike or sound-alike medications, says Mr. Kulczycki.

5. Ensure involvement of the leadership team. Leadership starts with the governing board, according to Ms. Bernicky. The leadership team is involved in educating the staff, monitoring compliance and keeping all documentation up-to-date and in order. They also set policies the staff members, surgeons and anesthesia providers follow.

Additionally, it is helpful if board meeting agendas and minutes reflect understanding and oversight of all processes which are in place, notes Ms. Yoder. If it isn't documented somewhere, one can ascertain that it wasn't done or communicated.

6. Make the accreditation process a team-based approach. The best practice is to make sure all members on the team are aware of accreditation needs, according to Ms. Yoder. While all team members should be trained on accreditation needs, it is good to have someone or a specific take the lead and make sure all chapters of the accreditation book are covered and all departments in the ASC have accountability related to specific needs.

"I was recently at a site where all the managers or team leads took a chapter of the AAAHC manual and met each week to ensure all processes where in place," she says. "They reveiwed their binders/paper work and went line item by line item. They believe that the time and energy spent now will pay off later in the year."  

7. Create a core team. An accreditation-focused team can include the administrator, a physician champion — an anesthesiologist or chair of the medical staff — as well as staff members who have expertise in infection prevention and environment of care. "What I have observed is that an ASC that takes a team approach and engages as many people as possible, uses mock surveys and conducts briefings throughout the year will be much better served when preparing for the accreditation survey as well as preparing for the next patient everyday," says Mr. Kulczycki.

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