Surgery center leaders' approach to the accreditation process plays a role in their evaluation, and ASC leaders who follow standards of practice but ignore elements like communication may have a reduced chance of earning accreditation. Michael Kulczycki, MBA, executive director of Ambulatory Care Accreditation for The Joint Commission, and John Olsen, MD, medical director of the Accreditation Association for Ambulatory Health Care, share common mistakes ambulatory surgery centers make when applying for accreditation.
1. Insufficient preparation. If ASC leaders do not start preparing for an accreditation inspection early enough, they may not be able to implement new practices throughout the organization. Dr. Olsen says the standards required for accreditation need to become ingrained in the culture of the center. "Make sure you roll out procedures and policies to all people who work there so they become encultured," he says. "It doesn't take a lot of time for experienced surveyors to walk through and see [there are] robust policies, but people out on the floor don't regularly use them. They don't think about them on a daily basis." ASC leaders have the responsibility to standardize practices early and communicate them to everyone in the center.
Both The Joint Commission and the AAAHC provide resources for ASCs applying for accreditation. Surgery center leaders should take advance of those resources to increase their chances of meeting all the requirements in time. Dr. Olsen suggests starting the process of applying for accreditation six months to a year before inspection. However, preparation does not end with learning the requirements and implementing processes. "Fulfillment [of requirements] requires education, training and constantly revisiting [processes] so the organization doesn't just reflect [standards] in the three-ring binder, but the halls of the institution reflect the same ideals," Dr. Olsen says. ASC administrators should continue to prepare the center for accreditation through mock surveys.
Mr. Kulczycki says administrators should perform a self-assessment prior to the survey "Have a team of your ASC staff go through and evaluate [the center] in real time," he says. He also suggests staff members evaluate processes in each other's departments to test compliance from a different perspective. "Mix up the staff; have fresh eyes look at the process," Mr. Kulczycki says. In addition, The Joint Commission requires ASCs to submit annual web-based assessments of their ongoing compliance between surveys.
2. Inadequate education. Dr. Olsen says accreditation has "a tremendous education component," and ASC leaders who fully understand the challenges in the accreditation process are more likely to succeed in accreditation. Both The Joint Commission and the AAAHC have written materials describing the standards required. "One of the most common mistakes that I think people overlook — and probably one of the easiest things you can do to pass with flying colors — is to get the current handbook," Dr. Olsen says. The Joint Commission publishes a list of the accreditation standards ASCs most frequently miss. For instance, the most recent list included granting privileges to surgeons on staff and safely storing medication.
Mr. Kulczycki offers two pieces of advice: "Always keep track of the top noncompliant standards and make sure you understand the language of the standards. If you're not sure what it means, The Joint Commission has a standard interpretation group available to help interpret the meaning." The Joint Commission also has a web-based leading practice library — available exclusively to accredited customers — that includes best practices and case examples of compliant centers. In addition to written materials, Dr. Olsen suggests administrators attend the AAAHC Achieiving Accreditation workshop, where the discussion centers on "being exposed to what it all involves."
3. Little commitment. ASCs may not achieve accreditation if leaders do not commit to making changes throughout the facility. Because of the amount of commitment needed, Dr. Olsen suggests administrators decide if accreditation aligns with the center's goals before beginning the process. "Make sure [accreditation] reflects not only what you do, but it embodies who you are and how you want to project yourself externally," he says. Commitment starts with the centers' leaders, who need to educate staff and delegate responsibilities so that staff become committed to the process as well. Dr. Olsen says each center should assign a small group of leaders to lead the accreditation effort and take responsibility for the results.
Mr. Kulczycki suggests that ASC leaders "chunk up" the 14 standards chapters, engage a broad spectrum of ASC staff in assessing current compliance, do a gap analysis and help implement improvements. For example, "Engage a surgical tech with responsibility for portions of the Environment of Care chapter and tap the business office manager to focus on compliance with requirements in the Patient Rights chapter," Mr. Kulczycki says.
4. Disconnection between staff and management. Disconnection between employees and leaders is one mistake that can cost an ASC accreditation. "Sometimes with all good intentions, processes can be uncoordinated because people who have different responsibilities are not tied together," Dr. Olsen says. Leaders can avoid disconnection within the center by communicating clearly and often. ASC administrators should also involve employees in applying for accreditation so they help implement necessary changes and understand the reason for these changes. "You need to educate and empower every single person — successful preparation is a shared commitment, one that often leads to accreditation and most importantly, great benefit to patients," Dr. Olsen says.
Empowerment of ASC staff becomes particularly evident with The Joint Commission's 'patient tracer' survey process, according to Mr. Kulczycki. "By using the patient's record as a 'roadmap' through the ASC, our surveyors engage most staff members, surgeons and anesthesiologists during the onsite process," he says.
Related Articles on Accreditation:
Florida Eye Institute Surgicenter in Vero Beach Achieves AAAHC Accreditation
Most Common Accreditation Problems in Orthopedic, Spine and Pain-Driven ASCs
Illinois' Physicians' Surgery Center Receives AAAHC Accreditation
1. Insufficient preparation. If ASC leaders do not start preparing for an accreditation inspection early enough, they may not be able to implement new practices throughout the organization. Dr. Olsen says the standards required for accreditation need to become ingrained in the culture of the center. "Make sure you roll out procedures and policies to all people who work there so they become encultured," he says. "It doesn't take a lot of time for experienced surveyors to walk through and see [there are] robust policies, but people out on the floor don't regularly use them. They don't think about them on a daily basis." ASC leaders have the responsibility to standardize practices early and communicate them to everyone in the center.
Both The Joint Commission and the AAAHC provide resources for ASCs applying for accreditation. Surgery center leaders should take advance of those resources to increase their chances of meeting all the requirements in time. Dr. Olsen suggests starting the process of applying for accreditation six months to a year before inspection. However, preparation does not end with learning the requirements and implementing processes. "Fulfillment [of requirements] requires education, training and constantly revisiting [processes] so the organization doesn't just reflect [standards] in the three-ring binder, but the halls of the institution reflect the same ideals," Dr. Olsen says. ASC administrators should continue to prepare the center for accreditation through mock surveys.
Mr. Kulczycki says administrators should perform a self-assessment prior to the survey "Have a team of your ASC staff go through and evaluate [the center] in real time," he says. He also suggests staff members evaluate processes in each other's departments to test compliance from a different perspective. "Mix up the staff; have fresh eyes look at the process," Mr. Kulczycki says. In addition, The Joint Commission requires ASCs to submit annual web-based assessments of their ongoing compliance between surveys.
2. Inadequate education. Dr. Olsen says accreditation has "a tremendous education component," and ASC leaders who fully understand the challenges in the accreditation process are more likely to succeed in accreditation. Both The Joint Commission and the AAAHC have written materials describing the standards required. "One of the most common mistakes that I think people overlook — and probably one of the easiest things you can do to pass with flying colors — is to get the current handbook," Dr. Olsen says. The Joint Commission publishes a list of the accreditation standards ASCs most frequently miss. For instance, the most recent list included granting privileges to surgeons on staff and safely storing medication.
Mr. Kulczycki offers two pieces of advice: "Always keep track of the top noncompliant standards and make sure you understand the language of the standards. If you're not sure what it means, The Joint Commission has a standard interpretation group available to help interpret the meaning." The Joint Commission also has a web-based leading practice library — available exclusively to accredited customers — that includes best practices and case examples of compliant centers. In addition to written materials, Dr. Olsen suggests administrators attend the AAAHC Achieiving Accreditation workshop, where the discussion centers on "being exposed to what it all involves."
3. Little commitment. ASCs may not achieve accreditation if leaders do not commit to making changes throughout the facility. Because of the amount of commitment needed, Dr. Olsen suggests administrators decide if accreditation aligns with the center's goals before beginning the process. "Make sure [accreditation] reflects not only what you do, but it embodies who you are and how you want to project yourself externally," he says. Commitment starts with the centers' leaders, who need to educate staff and delegate responsibilities so that staff become committed to the process as well. Dr. Olsen says each center should assign a small group of leaders to lead the accreditation effort and take responsibility for the results.
Mr. Kulczycki suggests that ASC leaders "chunk up" the 14 standards chapters, engage a broad spectrum of ASC staff in assessing current compliance, do a gap analysis and help implement improvements. For example, "Engage a surgical tech with responsibility for portions of the Environment of Care chapter and tap the business office manager to focus on compliance with requirements in the Patient Rights chapter," Mr. Kulczycki says.
4. Disconnection between staff and management. Disconnection between employees and leaders is one mistake that can cost an ASC accreditation. "Sometimes with all good intentions, processes can be uncoordinated because people who have different responsibilities are not tied together," Dr. Olsen says. Leaders can avoid disconnection within the center by communicating clearly and often. ASC administrators should also involve employees in applying for accreditation so they help implement necessary changes and understand the reason for these changes. "You need to educate and empower every single person — successful preparation is a shared commitment, one that often leads to accreditation and most importantly, great benefit to patients," Dr. Olsen says.
Empowerment of ASC staff becomes particularly evident with The Joint Commission's 'patient tracer' survey process, according to Mr. Kulczycki. "By using the patient's record as a 'roadmap' through the ASC, our surveyors engage most staff members, surgeons and anesthesiologists during the onsite process," he says.
Related Articles on Accreditation:
Florida Eye Institute Surgicenter in Vero Beach Achieves AAAHC Accreditation
Most Common Accreditation Problems in Orthopedic, Spine and Pain-Driven ASCs
Illinois' Physicians' Surgery Center Receives AAAHC Accreditation