Here are five tips when preparing for accreditation surveys.
1. Focus your staff on accreditation. For ambulatory service centers going through the survey for the first time, the obvious focus is to gain accreditation. However, for centers that are already accredited, Gina Dolsen, RN, BSN, MA, vice president of operations for Blue Chip Surgical Center Partners and an Accreditation Association for Ambulatory Health Care surveyor, said to make the survey work in the ASC’s favor. She recommended driving the surveyors to where the center needs help and to use the AAAHC to the center’s advantage. “A survey can be to your benefit; it doesn’t have to mean your demise,” Ms. Dolsen said.
Additionally, Ms. Dolsen said that ASCs should focus on topics that have been in the news leading up to the survey date. “If it has been in the news, it will be on the survey,” she said.
2. Comply with federal and state standards. In addition to the federal standards for Medicare accreditation, each of the nine designated regions in the country can interpret the standards differently, says David C. Watts, MD, the Vice President of Education for the American Association for Accreditation of Ambulatory Surgery Facilities(AAAASF). “The state can send in Medicare inspectors in addition to your deeming authority on the federal level, and how they interpret the standards may be different,” he says. It is therefore important to research the state-specific standards for accreditation prior to the inspection.
For example, the standards for the amount of dantrolene that must be stocked in an ambulatory surgery center differ at the state and federal levels. According to federal standards, the surgery center can have 12 vials in stock but must be able to obtain an additional 24 vials at a location within five minutes of the center, such as at a local hospital. However, according to the standards for region two, which encompasses part of the east coast, a surgery center is required to have all 36 vials stocked in its facility. In this case, the center must comply with whichever standard calls for the higher amount of stocked vials, says Dr. Watts.
3. 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., says 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 simply forget to get approval from the governing body [on matters related to quality improvement],” she says. “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.”
4. Revamp past policies. If at all possible, with permission from the appropriate personnel, surgery centers should use policies and procedures from previous workplaces as a template. By using policies and procedures from her previous hospital employer, Freida Toler, administrator at Amarillo (Texas) Endoscopy Center, saved time and energy needed to build policies from scratch and helped her facility more quickly achieve accreditation by the AAAHC.
“With permission from the hospital where I was the manager of the endoscopy lab, I brought over the policies and procedures that were used there and revamped them to fit the needs of our endoscopy center,” Ms. Toler says. “It required some changing because hospitals run in a completely different manner than ASCs.”
5. Stay updated with compliance all year. Accreditation requirements change throughout the year, so ASCs should set a goal of evaluating their current compliance now to start 2013 in line with standards.”As you’re approaching the final few months of the year,” Jessica Nantz, president of Outpatient Healthcare Strategies, says, “if you’ve missed any federal, state or accreditation requirements that require your ASC to conduct [some task or survey] annually, make sure to address these annual requirements.”
Medicare standards can be particularly complex, and it is easy for ASCs to develop gaps in compliance without noticing. “On a practical level, whenever you do periodic assessment on your operational compliance, you will find gaps,” Regina Boore, RN, principal and CEO of Progressive Surgical Solutions, says. “You may find gaps that weren’t there before or a gap that now is the time to address.”
She said these can include gaps in physician behaviors, such as improperly discarding masks, which may require ongoing monitoring and reinforcement. Starting now rather than waiting will to establish these compliant behaviors.
Mandatory quality reporting also began Oct. 1. “If you haven’t educated your staff as to the quality reporting requirements, you need to do as soon as possible,” she says. “All surgeons and staff need to know what their role is in capturing data and getting it to coders and billers in a timely manner.”
Ms. Simkow says ASCs can prevent this by making quality issues a standard agenda item during governing body meetings.
“The majority of Medicare facilities don’t know this [difference between federal and state standards] exists unless they have some sort of interaction with the state,” he says. “But that’s important because if you don’t know about this ahead of time, there’s no way you’re going to pass a validation survey performed by State agency surveyors.”
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