Achieving accreditation from any accrediting organization is a notable accomplishment but no easy feat and requires a long process of preparation. Adele Rittmueller, CEO of Flathead Orthopedics and Orthopedic Surgery Center in Kalispell, Mont., which was recently accredited by AAAHC for the first time, shares the five steps her surgery center took to accomplish the task.
1. Start preparing well ahead of time. Since the ambulatory surgery center had no previous experiences to rely on, Ms. Rittmueller knew the only way to be successful was to prepare for the survey well in advance. The preparation process did not take place a couple months before the survey — Ms. Rittmueller started the process years in advance.
"Our center worked very hard for several years in order to understand, study and meet all of the standards that are established by CMS and AAAHC," she says. "It demands so much attention and diligence that it can't be treated as a last-minute quick study."
The key to preparing for a survey, however, is that it is ongoing. Preparing for a survey should not end as soon as the onsite visit from an inspector ends. "We really focus on making it meaningful so we continue to follow the standards. We don't train our staff to understand the standards just to pass the survey," she says.
2. Put together a team to spearhead preparation. Ms. Rittmueller sought out the medical director and clinical director for help on preparing for the survey. The three-person team, she says, was a strategic move in that each individual had a skill or expertise that was brought to the table. Qualities that are important to possess in a team that heads up accreditation preparation efforts are attention to detail, organizational skills and planning skills.
"We studied the standards to determine which areas we needed to put more of our efforts into," she says. "It's important to understand why the standards were established and what they meant to accomplish so that we can then understand how to make them meaningful for our center. The combination of all our skills, though, made it easier to get this work done."
3. Filter information down through the ranks. Once the leadership team researched the standards, that information was filtered down through the ranks. Infection control officer, patient safety officers, quality assurance coordinators all need to be kept apprised of the standards so they can take the appropriate steps to tackle the related challenges.
"Although the direction comes from the top, it's the registered nurses, the staff and all the individuals on committees that help us achieve accreditation," Ms. Rittmueller says. "We have to be reviewing, revising and directing that process because we have a perspective at the management level, but the staff is intimately involved. It is a leader-led but staff-driven process."
4. Focus on quality improvement. Although all accreditation standards are important in order to maintain patient safety, quality improvement is at the heart of it all. Without a proper quality improvement process in place, ASCs will be hard-pressed to find areas of weakness to improve upon. Ms. Rittmueller says the staff is proactive in identifying even a small, question or event that would have the potential to become an adverse event.
"The staff really drives that process of identifying and formally reporting anything that happens out of the ordinary," she says. "Every adverse event is also discussed at quarterly quality meetings."
One such quality improvement study that was initiated by a staff member was recovery periods following spine injections. "Some nurses noticed trends with the initial recovery period of an injection that resulted in more pain and numbness, so we investigated that. This type of re-examining has to be part of a center's day-to-day culture," she says.
5. Stay connected. Stay up-to-date and network with other healthcare facilities. This is an easy two-pronged approach to how ASCs can be compliant with accreditation standards. Ms. Rittmueller says the center is diligent in staying up-to-date with patient safety issues through reading articles released by the Association of periOperative Registered Nurses and other organizations and by attending local and national conferences on patient safety. The center also turns to a surprising source for more information on patient safety best practices — its competitors.
"We don't hesitate to contact and network with our peers in the state to see how they've approached a certain accreditation standard," Ms. Rittmueller says. "We rarely integrate someone else's process or form without reviewing and revising their best practices to work for our surgery center."
Learn more about The Orthopedic Surgery Center.
1. Start preparing well ahead of time. Since the ambulatory surgery center had no previous experiences to rely on, Ms. Rittmueller knew the only way to be successful was to prepare for the survey well in advance. The preparation process did not take place a couple months before the survey — Ms. Rittmueller started the process years in advance.
"Our center worked very hard for several years in order to understand, study and meet all of the standards that are established by CMS and AAAHC," she says. "It demands so much attention and diligence that it can't be treated as a last-minute quick study."
The key to preparing for a survey, however, is that it is ongoing. Preparing for a survey should not end as soon as the onsite visit from an inspector ends. "We really focus on making it meaningful so we continue to follow the standards. We don't train our staff to understand the standards just to pass the survey," she says.
2. Put together a team to spearhead preparation. Ms. Rittmueller sought out the medical director and clinical director for help on preparing for the survey. The three-person team, she says, was a strategic move in that each individual had a skill or expertise that was brought to the table. Qualities that are important to possess in a team that heads up accreditation preparation efforts are attention to detail, organizational skills and planning skills.
"We studied the standards to determine which areas we needed to put more of our efforts into," she says. "It's important to understand why the standards were established and what they meant to accomplish so that we can then understand how to make them meaningful for our center. The combination of all our skills, though, made it easier to get this work done."
3. Filter information down through the ranks. Once the leadership team researched the standards, that information was filtered down through the ranks. Infection control officer, patient safety officers, quality assurance coordinators all need to be kept apprised of the standards so they can take the appropriate steps to tackle the related challenges.
"Although the direction comes from the top, it's the registered nurses, the staff and all the individuals on committees that help us achieve accreditation," Ms. Rittmueller says. "We have to be reviewing, revising and directing that process because we have a perspective at the management level, but the staff is intimately involved. It is a leader-led but staff-driven process."
4. Focus on quality improvement. Although all accreditation standards are important in order to maintain patient safety, quality improvement is at the heart of it all. Without a proper quality improvement process in place, ASCs will be hard-pressed to find areas of weakness to improve upon. Ms. Rittmueller says the staff is proactive in identifying even a small, question or event that would have the potential to become an adverse event.
"The staff really drives that process of identifying and formally reporting anything that happens out of the ordinary," she says. "Every adverse event is also discussed at quarterly quality meetings."
One such quality improvement study that was initiated by a staff member was recovery periods following spine injections. "Some nurses noticed trends with the initial recovery period of an injection that resulted in more pain and numbness, so we investigated that. This type of re-examining has to be part of a center's day-to-day culture," she says.
5. Stay connected. Stay up-to-date and network with other healthcare facilities. This is an easy two-pronged approach to how ASCs can be compliant with accreditation standards. Ms. Rittmueller says the center is diligent in staying up-to-date with patient safety issues through reading articles released by the Association of periOperative Registered Nurses and other organizations and by attending local and national conferences on patient safety. The center also turns to a surprising source for more information on patient safety best practices — its competitors.
"We don't hesitate to contact and network with our peers in the state to see how they've approached a certain accreditation standard," Ms. Rittmueller says. "We rarely integrate someone else's process or form without reviewing and revising their best practices to work for our surgery center."
Learn more about The Orthopedic Surgery Center.