Lessons learned: Rebounding from AAAHC certification deficiencies

After reading a recent Becker's ASC Review article offering tips to help new centers achieve AAAHC certification, I started thinking about my own center's certification. As Arkansas Specialty Surgery Center opened in 1998, my most recent experience with AAAHC certification was vastly different than that of a new center. However, my positive experience in enlisting the help of an outside consultant is something I share in common with the author of that piece.

norman bBefore I joined Arkansas Specialty, an earlier CMS survey had uncovered significant deficiencies at the center. Nearly three years later I was brought onboard. After assessing the situation I learned many of the issues had not been fixed, and some additional issues had arisen. Because the management group and most of the staff at the center were from a hospital or physician clinic environment, the additional concerns were largely the result of a lack of ASC-specific expertise.

Realizing the task at hand was larger than one person could handle, I sought the assistance of an outside consultant to lead the team that would resolve these issues -- Ann Geier, chief nursing officer at SourceMed Professional Services. My goal in hiring an outside consultant was to educate staff and the management company on the severity of the issues. Ms. Geier provided the much needed neutral third-party expert advice and ASC-specific experience that the team needed.

Education is key

Hiring a consultant to come in and tell management and staff what needs to be fixed is not enough. Simply stating that something has to be done because it is regulation will not change behaviors. Ms. Geier's ability to educate our team on the severity of each issue and the impact to our center was extremely valuable to gaining buy-in for what needed to be done, which helped accelerate the resolution process.

For example, patient safety is a top priority at Arkansas Specialty. While the center has a great patient safety record, without proper documentation it didn't matter in the eyes of a surveyor.  More than just stating that documentation must be done properly and writing policies and procedures for staff to follow, our consultant took the time to educate staff and management on why things must be done a certain way.

A hospital OR and an ASC run very differently. Because Arkansas Specialty staff are primarily hospital employees leased from our sister facility, and the management company's expertise was also limited to physician clinical operations, most of the policies and procedures at the center reflected hospital operations. Policies, procedures, and protocols for hospitals are substantially different than those written for ASCs. Ms. Geier educated our team on the differences and worked with us to implement the proper policies, protocols and procedures for an ASC setting, which is key to obtaining AAAHC certification.

Reputation matters

There are very few individuals that offer the broad-based knowledge and expertise Ms. Geier brought to the table. Having a consultant with significant understanding of how an ASC operates was key to our center successfully resolving CMS and AAAHC deficiencies.

My advice to other facilities going through AAAHC certification: there is a tremendous amount of work that has to be done; if you are unable to take on the work or don't have the expertise in-house, outsource it to a seasoned ASC professional. Because not all consultants are equal, understand what you want in a consultant and do your homework. The consultant you hire should be well-respected in the ASC industry and have significant experience specific to ASCs as well as a clinical background. Inquire about how they work; will they spend time educating your staff? Will you be able to follow-up with additional questions after the engagement ends? Lastly, they should have a continuous focus on educating themselves on the ASC industry so that their knowledge is current.

More accreditation news:
North Shore Endoscopy Center earns accreditation: 3 key notes
Selarom Surgical Center earns AAAASF accreditation: 4 highlights
5 tips for AAAHC certification of a new center

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