"We were successful in allocating resources to being able to do more random surveys," says Karen L. Hornberger, director of marketing and communications for AAAHC. "It's just a general quality healthcare initiative."
AAAHC has always reserved the right to perform random surveys of its organizations, and in 2002 the accreditor formalized the random survey process as it works today, which lets AAAHC support its ongoing quality assurance initiatives.
If you're accredited by the Joint Commission, the unannounced survey process is now a way of life. An organization that was due for a survey between 2006 and this year would have had its unannounced survey in the year that the organization is due for a triennial survey. Subsequent unannounced surveys would fall 18 to 39 months after the organization's first unannounced survey, according to the Joint Commission's Web site.
The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) also performs random, unannounced surveys, a practice started two years ago. These surveys are sometimes triggered by a death at a facility or if a complaint is filed against an organization, but throughout the year, the accreditor will also make a random number of visits to organizations without prerequisite, says Jeff Pearcy, MPA, CAE, executive director of AAAASF.
The message to organizations about the purpose of the random survey process is simple: remain prepared, not only to maintain accreditation but for the well-being of your patients.
"We like to say that accreditation is a continuous process. It does not start or stop with a survey. This is a way to get us out there and make sure everyone's doing what they should be," says Ms. Hornberger.
Here are six quick tips from Joan Dentler, MBA, co-founder of ASC Strategies, an ASC consulting firm, to help ensure your organization is prepared in the event that a surveyor appears at your door unexpectedly.
1. Annually appoint an "accreditation team leader." This leader's responsibilities would include reviewing standards, keeping up-to-date with industry articles on accreditation and compiling necessary documents -- minutes, quality improvement (QI) studies, etc. -- in an orderly and surveyor-friendly format, Ms. Dentler says. The leader can prepare memos or newsletters providing good accreditation preparation tips and practices to distribute to the staff. This leader can also provide updates to the board of directors and investors about accreditation and safety-related projects that are pending and recently completed, or make proposals about projects, such as new QI studies or training exercises, which the leader feels may help with maintaining accreditation.
To fill this responsibility, an organization will want to identify an individual with a good relationship with the staff who can help obtain staff buy-in for accreditation efforts. The right person for the assignment will have strong organizational skills and a capacity in their workload to allocate a few hours each week to the accreditation-related tasks, so it may not be wise to assign this responsibility to the administrator given an administrator's time constraints.
2. Designate a backup contact. Many organizations expect the administrator to serve as the primary contact during a survey. This is a fine practice, but organizations must be prepared if surveyors arrive when the administrator is not present or available. Make sure that another member of the staff, such as the designated accreditation team leader, is prepared to take the lead. This backup contact should know the location of all relevant documentation, be able to speak confidently about the practices of the ASC and also know how to properly verify a surveyor's identification upon arrival.
3. Make accreditation a standing agenda item. Make accreditation efforts a standing agenda item for staff, medical executive committee and board of directors meetings.
"This will keep the issue on everyone's radar in between surveys," Ms. Dentler says.
4. Allocate funds for accreditation preparation. Include a budget line item for accreditation preparation in every annual operating budget. These funds can be spent on the actual application and expenses associated with a survey in years when a survey is expected. In off-years, make sure funds are available for on- and off-site training, materials and tools, or possibly the hiring of consultants to help your ASC remain prepared to meet the latest accreditation and safety practices and trends.
"Having accreditation as a line-item in the budget also illustrates to the board and investors a strong commitment to the accreditation process and not just leaving it all up to the staff to make it happen on their own on top of their everyday jobs," Ms. Dentler says.
5. Conduct mock surveys. "Performing unannounced and seriously-conducted mock surveys is an excellent practice," Ms. Dentler says. "It is fine to have these done by someone on the staff, but it is really better if it is a fresh pair of eyes that won't make any subconscious excuses for things left undone, such as the 'they had so many cases yesterday they couldn't get that all together in time' reason."
Consider talking to a neighboring ASC and see if you can perform mock surveys on each other. There are also many consultants that you can hire for this service.
6. Stay vigilant. It's easy to become complacent with your efforts to maintain compliance with accreditation standards, but doing so can potentially hurt your organization and harm your patients. Try to make accreditation as much of a priority as your other top issues.
"Our firm is engaged by ASCs to conduct quarterly, biannual or annual operational assessments of ASCs around the country and we always suggest that they include accreditation standards as a part of the scope of our assessments," Ms. Dentler says. "That way, the center not only gets a report on the center's performance with coding, reimbursement, staffing levels, supply costs and physician satisfaction, but also readiness for their accreditation survey."