At the 11th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference June 13, Steven A. Gunderson, DO, CEO and medical director of Rockford (Ill.) Ambulatory Surgery Center and surveyor for the Accreditation Association for Ambulatory Health Care, discussed common accreditation problems in ASCs.
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.
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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.
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