Ray Grundman, AAAHC surveyor, explains three of the most common deficiencies found during accreditation surveys.
1. Notifying or asking patients about advanced directives. Under the Patient Self-Determination Act, healthcare providers, including ASCs, are required to proactively ask and solicit patients about advance directives, which are legal documents patients can prepare ahead of time that would speak for them on healthcare issues, Mr. Grundman says.
"For example, an advance directive might document that if a patient had a stroke, they would want to be resuscitated, or they may want everything possible to be done in order to be resuscitated. The point is that it is all put on paper," he says. "ASCs have every intention of having every patient walking or wheel-chaired out of the facility alive and breathing because they come to the ASC for elective procedures, but the concept of asking patients if they have an advance directive is relatively new."
Mr. Grundman, who conducts two to three surveys a month, says this deficiency is found in roughly 50 percent of the surveys he conducts. "I'm looking for some written policy or procedure that all the staff members have been trained on and evidence that policy and procedure was applied," he says. Mr. Grundman suggests ASCs scan the advance directives directly into patient records if they have an electronic health record system or place a paper copy of the advance directive on the chart if it is a paper chart. The presence of an advance directive in the patient’s chart should also be noted prominently somewhere in or on the chart.
2. Ensuring the ASC is compliant with all laws and regulations. Mr. Grundman says some ASCs lack a formal written policy that identifies the governing body's responsibility for ensuring that the organization is in full compliance with all local/state/federal laws, statutes, rules and regulations. In order to accomplish this, the organization may set up a corporate compliance program. The program should make sure compliance issues are identified and physicians and staff are educated on compliance to these regulations.
"We expect the governing body to ensure the organization is in compliance with all the known regulations that apply to them, and the deficiency we find most often in relation to this accreditation standard is identifying the governing body's responsibility," Mr. Grundman says. "Somehow, the body needs to explicitly state they know to establish such a compliance program so that there is a process of staying up-to-date on compliance issues."
Mr. Grundman says there are several ways ASCs can implement a compliance program. ASCs have the option of hiring an experienced healthcare attorney to keep the ASC regularly updated on compliance issues or sending administrators to compliance meetings to stay well-informed.
3. Ensuring patients are notified of laboratory results. Another accreditation standard that many ASCs have difficulty with is the requirement that patients are contacted as quickly as possible for follow-up regarding significant problems and/or abnormal laboratory or radiological findings. This poses a challenge for ASCs, who may find it difficult to ensure physicians made contact with their patients and demonstrate that contact was established. Mr. Grundman says this can be remedied by first assigning this responsibility to the members of the medical staff by including this responsibility in the organization’s medical staff bylaws, or rules and regulations. This ensures physicians are cognizant that it is their responsibility — not the ASC's — to notifying patients of their results. However, Mr. Grundman warns ASCs must also implement a second line of defense to ensure all patients are truly notified.
"ASCs still need a feedback loop or mechanism that makes sure these contacts are happening," he says. "Some organizations follow up with phone calls to patients. Some organizations put notes on patients' discharges notes to expect a phone call from their physicians about the lab results. That's the safety net we're asking ASCs to establish to make sure nothing falls through the cracks."
Learn more about AAAHC.
1. Notifying or asking patients about advanced directives. Under the Patient Self-Determination Act, healthcare providers, including ASCs, are required to proactively ask and solicit patients about advance directives, which are legal documents patients can prepare ahead of time that would speak for them on healthcare issues, Mr. Grundman says.
"For example, an advance directive might document that if a patient had a stroke, they would want to be resuscitated, or they may want everything possible to be done in order to be resuscitated. The point is that it is all put on paper," he says. "ASCs have every intention of having every patient walking or wheel-chaired out of the facility alive and breathing because they come to the ASC for elective procedures, but the concept of asking patients if they have an advance directive is relatively new."
Mr. Grundman, who conducts two to three surveys a month, says this deficiency is found in roughly 50 percent of the surveys he conducts. "I'm looking for some written policy or procedure that all the staff members have been trained on and evidence that policy and procedure was applied," he says. Mr. Grundman suggests ASCs scan the advance directives directly into patient records if they have an electronic health record system or place a paper copy of the advance directive on the chart if it is a paper chart. The presence of an advance directive in the patient’s chart should also be noted prominently somewhere in or on the chart.
2. Ensuring the ASC is compliant with all laws and regulations. Mr. Grundman says some ASCs lack a formal written policy that identifies the governing body's responsibility for ensuring that the organization is in full compliance with all local/state/federal laws, statutes, rules and regulations. In order to accomplish this, the organization may set up a corporate compliance program. The program should make sure compliance issues are identified and physicians and staff are educated on compliance to these regulations.
"We expect the governing body to ensure the organization is in compliance with all the known regulations that apply to them, and the deficiency we find most often in relation to this accreditation standard is identifying the governing body's responsibility," Mr. Grundman says. "Somehow, the body needs to explicitly state they know to establish such a compliance program so that there is a process of staying up-to-date on compliance issues."
Mr. Grundman says there are several ways ASCs can implement a compliance program. ASCs have the option of hiring an experienced healthcare attorney to keep the ASC regularly updated on compliance issues or sending administrators to compliance meetings to stay well-informed.
3. Ensuring patients are notified of laboratory results. Another accreditation standard that many ASCs have difficulty with is the requirement that patients are contacted as quickly as possible for follow-up regarding significant problems and/or abnormal laboratory or radiological findings. This poses a challenge for ASCs, who may find it difficult to ensure physicians made contact with their patients and demonstrate that contact was established. Mr. Grundman says this can be remedied by first assigning this responsibility to the members of the medical staff by including this responsibility in the organization’s medical staff bylaws, or rules and regulations. This ensures physicians are cognizant that it is their responsibility — not the ASC's — to notifying patients of their results. However, Mr. Grundman warns ASCs must also implement a second line of defense to ensure all patients are truly notified.
"ASCs still need a feedback loop or mechanism that makes sure these contacts are happening," he says. "Some organizations follow up with phone calls to patients. Some organizations put notes on patients' discharges notes to expect a phone call from their physicians about the lab results. That's the safety net we're asking ASCs to establish to make sure nothing falls through the cracks."
Learn more about AAAHC.