The on-site survey is the final and most important step in the nuanced process of earning accreditation from the Accreditation Association for Ambulatory Health Care. To achieve AAAHC accreditation, ambulatory surgery centers must undergo a detailed process that includes an application, a self-evaluation and the survey itself.
Surveys are conducted by healthcare professionals and administrators, who are actively involved in the ambulatory healthcare arena. The survey is what ultimately determines whether an ASC can claim to be an AAAHC-accredited facility or not.
Nancy Jo Vinson, RN, BA, CASC, owner and president of NJM Consulting and an AAAHC surveyor, says that the survey focuses on three basic aspects, namely whether the center has a set of policies and procedures; whether they address the standards of AAAHC and related agencies; and whether they are being followed by the facility as a whole.
During the survey, AAAHC surveyors follow a patient through an episode of care at the center. Surveyors observe surgical procedures and watch for appropriate patient preparation before and after surgery as well as infection control practices of staff and providers, says Scott Trimas, MD, owner of Atlantic Surgery Center of Jacksonville Beach (Fla.) and an AAAHC surveyor.
More often than not, there are areas of survey preparation that ASCs tend to overlook, which can result in denial of accreditation. Here are seven areas that are most commonly overlooked by ASCs:
1. Creating a culture of compliance. ASCs tend to forget to incorporate policies and procedures into its organization's culture. "The biggest mistake I see made is hiring a consultant and relying on them solely," says Dr. Trimas.
While consultants can offer valuable guidance during the accreditation process, organizations need to make sure the policies it has in place become a part of the internal culture of an organization. The on-site survey also includes brief interviews with key staff members to ensure the organization's policies are communicated to all employees.
2. Maximizing staff preparedness. Facility leaders are required to communicate details to their staff about the survey process, such as what the surveyors are going to evaluate. They also ensure the staff has up-to-date information regarding facility policies and procedures. "When the staff isn't ready for a survey, it can lead to the organization's downfall," says Ms. Vinson.
ASCs tend to overlook employee orientation, which should take place 30 days after the date of hire, according to Marshall Baker, president and CEO of Physician Advisory Services and an AAAHC surveyor. Employee orientation involves helping new hires become familiar with the daily functioning of the ASC as well as the guidelines it follows. It is essential that the staff follow appropriate policies and procedures from the get go since AAAHC surveyors check whether the staff knows them well. Annual reorientation is another requirement, and surveyors will be looking for documentation of completion in the employee's HR record, says Mr. Baker.
Surgery center leaders don't always make sure that their staff is following the center's policies in an appropriate manner, says Ms. Vinson. One way to keep a tab on whether all changes in policies are being communicated through the center is to hold a meeting and record its minutes. Other ways include sending an email communicating the news and asking the entire team to acknowledge the email or having a communication book that contains all information to be communicated, which personnel are required to initial when they read the information.
"Don't tell the surveyor 'I just tell everyone as I see them' because there is no way for the surveyor to confirm that the information was communicated," she says.
3. OSHA guideline adherence. Since staff training includes a number of different elements — infection training, risk management, orientation of job duties and so on. It is important that ASC leaders ensure that the staff is familiar with the appropriate Occupational Safety and Health Administration guidelines. Dr. Trimas says some of the most common OSHA guidelines missed at ASCs include:
• Annual safer device checks
• Proper biohazardous labeling
• Proper biohazardous material storage
4. AAAHC standard compliance. "ASCs look at the AAAHC standards but they sometimes don't think about the standards," says Ms. Vinson. Organization leaders need to think about how the standards are applicable to their facility. They shouldn't assume that if a standard isn't directly applicable, it isn't applicable at all. "More often than not it is about how the standard applies rather than if it applies."
They also need to seek out information that isn't necessarily laid out in the handbook. For example, facilities that have a CLIA Certificate of Waiver — a certificate that allows laboratory testing for certain procedures that have insignificant risk — must have certain internal and external controls according to the AAAHC. But the handbook does not detail what these controls are, says Ms. Vinson. ASC leaders can find this information on the CLIA website.
It's also important to obtain the current handbook for the accreditation year since the handbook and standards change every year. "This might seem obvious, but it is not always followed," says Ms. Vinson. "I have done surveys at centers that have a handbook which is five years old."
5. Policies review for contradictions. According to Ms. Vinson, surgery centers will sometimes implement new policies without reviewing the policies they already have in place. This leads to policies that contradict each other. She recommends regularly reviewing the center's policies and streamlining them. Surveyors will look for documented periodic reviews and approval of current policies, says Mr. Baker.
6. Up-to-date privileges. Dr. Trimas says ASC leaders also make the mistake of forgetting to ensure privilege lists are up-to-date, especially for sedation, supervision of sedation and use of radiological equipment with interpretation.
7. Honesty about holes in preparation. If an ASC begins to discover holes in its preparation during the survey, there is only one thing the ASC should do: be honest with the surveyor, says Dr. Trimas. "Trying to hide something can actually frustrate the surveyor and prolong the process and potentially affect your outcome."
ASC leaders can initiate an action plan to put corrective actions in motion before the end of the site visit, says Mr. Baker. If the problem is something the center can fix and present to the surveyors before the survey is completed, it is usually accepted.
"AAAHC tries to be as consultative as possible," says Ms. Vinson. "It's not prescriptive; however, the end result needs to be compliance with the standards."
AAAHC Approved to Accredit Qualified Health Plans
AAAHC Accredits GastroIntestinal Healthcare
Surveys are conducted by healthcare professionals and administrators, who are actively involved in the ambulatory healthcare arena. The survey is what ultimately determines whether an ASC can claim to be an AAAHC-accredited facility or not.
Nancy Jo Vinson, RN, BA, CASC, owner and president of NJM Consulting and an AAAHC surveyor, says that the survey focuses on three basic aspects, namely whether the center has a set of policies and procedures; whether they address the standards of AAAHC and related agencies; and whether they are being followed by the facility as a whole.
During the survey, AAAHC surveyors follow a patient through an episode of care at the center. Surveyors observe surgical procedures and watch for appropriate patient preparation before and after surgery as well as infection control practices of staff and providers, says Scott Trimas, MD, owner of Atlantic Surgery Center of Jacksonville Beach (Fla.) and an AAAHC surveyor.
More often than not, there are areas of survey preparation that ASCs tend to overlook, which can result in denial of accreditation. Here are seven areas that are most commonly overlooked by ASCs:1. Creating a culture of compliance. ASCs tend to forget to incorporate policies and procedures into its organization's culture. "The biggest mistake I see made is hiring a consultant and relying on them solely," says Dr. Trimas.
While consultants can offer valuable guidance during the accreditation process, organizations need to make sure the policies it has in place become a part of the internal culture of an organization. The on-site survey also includes brief interviews with key staff members to ensure the organization's policies are communicated to all employees.
2. Maximizing staff preparedness. Facility leaders are required to communicate details to their staff about the survey process, such as what the surveyors are going to evaluate. They also ensure the staff has up-to-date information regarding facility policies and procedures. "When the staff isn't ready for a survey, it can lead to the organization's downfall," says Ms. Vinson.
ASCs tend to overlook employee orientation, which should take place 30 days after the date of hire, according to Marshall Baker, president and CEO of Physician Advisory Services and an AAAHC surveyor. Employee orientation involves helping new hires become familiar with the daily functioning of the ASC as well as the guidelines it follows. It is essential that the staff follow appropriate policies and procedures from the get go since AAAHC surveyors check whether the staff knows them well. Annual reorientation is another requirement, and surveyors will be looking for documentation of completion in the employee's HR record, says Mr. Baker.
Surgery center leaders don't always make sure that their staff is following the center's policies in an appropriate manner, says Ms. Vinson. One way to keep a tab on whether all changes in policies are being communicated through the center is to hold a meeting and record its minutes. Other ways include sending an email communicating the news and asking the entire team to acknowledge the email or having a communication book that contains all information to be communicated, which personnel are required to initial when they read the information.
"Don't tell the surveyor 'I just tell everyone as I see them' because there is no way for the surveyor to confirm that the information was communicated," she says.
3. OSHA guideline adherence. Since staff training includes a number of different elements — infection training, risk management, orientation of job duties and so on. It is important that ASC leaders ensure that the staff is familiar with the appropriate Occupational Safety and Health Administration guidelines. Dr. Trimas says some of the most common OSHA guidelines missed at ASCs include:
• Annual safer device checks
• Proper biohazardous labeling
• Proper biohazardous material storage
4. AAAHC standard compliance. "ASCs look at the AAAHC standards but they sometimes don't think about the standards," says Ms. Vinson. Organization leaders need to think about how the standards are applicable to their facility. They shouldn't assume that if a standard isn't directly applicable, it isn't applicable at all. "More often than not it is about how the standard applies rather than if it applies."
They also need to seek out information that isn't necessarily laid out in the handbook. For example, facilities that have a CLIA Certificate of Waiver — a certificate that allows laboratory testing for certain procedures that have insignificant risk — must have certain internal and external controls according to the AAAHC. But the handbook does not detail what these controls are, says Ms. Vinson. ASC leaders can find this information on the CLIA website.
It's also important to obtain the current handbook for the accreditation year since the handbook and standards change every year. "This might seem obvious, but it is not always followed," says Ms. Vinson. "I have done surveys at centers that have a handbook which is five years old."
5. Policies review for contradictions. According to Ms. Vinson, surgery centers will sometimes implement new policies without reviewing the policies they already have in place. This leads to policies that contradict each other. She recommends regularly reviewing the center's policies and streamlining them. Surveyors will look for documented periodic reviews and approval of current policies, says Mr. Baker.
6. Up-to-date privileges. Dr. Trimas says ASC leaders also make the mistake of forgetting to ensure privilege lists are up-to-date, especially for sedation, supervision of sedation and use of radiological equipment with interpretation.
7. Honesty about holes in preparation. If an ASC begins to discover holes in its preparation during the survey, there is only one thing the ASC should do: be honest with the surveyor, says Dr. Trimas. "Trying to hide something can actually frustrate the surveyor and prolong the process and potentially affect your outcome."
ASC leaders can initiate an action plan to put corrective actions in motion before the end of the site visit, says Mr. Baker. If the problem is something the center can fix and present to the surveyors before the survey is completed, it is usually accepted.
"AAAHC tries to be as consultative as possible," says Ms. Vinson. "It's not prescriptive; however, the end result needs to be compliance with the standards."
More Articles on Accreditation:
AAAASF Accredits Atlantic Plastic Surgery CenterAAAHC Approved to Accredit Qualified Health Plans
AAAHC Accredits GastroIntestinal Healthcare