The most common problems are usually simple and they have simple solutions, Dr. Gunderson says. Here are some accreditation pitfalls and ways to avoid them:
Problem: Failure to obtain the appropriate AAAHC handbook.
Solution: The AAAHC handbook changes every year, so centers should obtain one annually.
Problem: Failure to conduct an ASC self-assessment prior to survey.
Solution: Administrators should assess their centers to determine if they meet standards before surveyors come.
Problem: Failure to address problematic standards following self-assessment if performed.
Solution: After ASCs conduct self-assessments, they should develop action plans to address areas that did not meet standards.
Problem: Failure to engage ASC staff.
Solution: Dr. Gunderson said RASC develops a newsletter for staff that has key standards from each chapter of the AAAHC handbook on the left-hand side of the page and an explanation of how the center meets those standards on the right-hand side. These explanations help engage staff in the accreditation process.
Problem: Physicians do not specifically request to administer local anesthesia as a core privilege even though it is performed.
Solution: Add “administration of local anesthesia” to the center’s core privileges definition.
Problem: Peer review is not actively ongoing.
Solution: Conduct peer review at least annually.
Problem: There is no time limit for privileging, or it is defined only in the bylaws and medical staff rules and regulations.
Solution: Establish privileging time limits in a letter sent to the provider and/or in the minutes of the governing body.
Problem: The quality management and improvement program is approved by the governing body when implemented, but has never been reviewed since.
Solution: The governing body should review the quality management and improvement program annually and document the review in its minutes.
More Articles on Accreditation:
HFAP Releases Online Version of ASC Accreditation Requirements Manual
Tools & Technology to Make ASC Accreditation Easier: Q&A With CEO of Accreditation Solutions Alliance Dr. David Watts
5 Areas That Trip Up ASCs During Accreditation Evaluations
