Ray Grundman, senior director of external relations at the Accreditation Association for Ambulatory Health Care and AAAHC surveyor, gives an inside look at nine common stumbling blocks along the road to a successful ambulatory surgery center accreditation survey. Accreditation surveys are a necessary part of keeping a surgery center's doors open. Accreditation is not only necessary, but demonstrates an ASC's commitment to quality patient care. "Survey success rates are high, but there is always a better way to do it," says Ray Grundman, senior director of external relations at the Accreditation Association for Ambulatory Health Care and AAAHC surveyor.
Here are nine frequent accreditation mistakes made in surgery centers and tips on how to avoid these slip-ups.
1. Preparation based on an outdated handbook. AAAHC publishes a new handbook each year, but surgery centers undergo accreditation surveys every three years. "We are going to perform the survey based on the 2013 handbook, even if the ASC is working off of the 2010 handbook," says Mr. Grundman. The 2013 handbook included a number of significant changes, such as the requirement of exhaled CO2 monitoring in deep sedation patients. Surgery centers that prepare based on an out-dated set of AAAHC standards might encounter survey scoring of partial or non compliance ..
Though using a handbook outdated by several years seems a fairly obvious mistake, it becomes easier to make this error around the time AAAHC transitions from one year's handbook to the next. If a surgery center survey is booked before March 1 of the year and performed before June 30 of that year, the survey will be based on the previous year’s handbook, while a survey booked or performed after those dates will be subject to the next year’s handbook.
AAAHC announces changes made to its handbook well in advance and posts the changes to its website. The 2014 updates, expected to be less extensive than in 2013, will be released within the next few weeks.
2. Inaccurate contact information. An out-dated handbook can often be traced back to inaccurate contact information. Each survey application requires a contact person's information. This person receives all information and materials from AAAHC, including new handbooks. "We know that there is turnover and swapping of duties, but it's important to keep that information up-to-date," says Mr. Grundman. If surgery center leaders anticipate a change in contact information, they should contact AAAHC via letter or email. Information in written form allows AAAHC to verify that the organization itself is requesting the change.
3. Rushed or late application submission. Surgery center leaders and staff put in a great deal of time preparing for accreditation, but the same goes for the teams responsible for conducting the surveys. "If an ASC's leaders decide to send in an application a month before the accreditation expiration date, it becomes very difficult to put together a team," says Mr. Grundman. AAAHC encourages surgery center leaders to send in applications six months in advance.
Allowing for ample time prior to the accreditation expiration date benefits the team getting ready to visit and the center itself. Surgery center leaders will often want a surveyor with a particular background, such as an anesthesiologist, to be a part of the survey team. "The more time we have, the more likely we will be able to work with organization preferences," says Mr. Grundman.
4. Rescheduled survey date. Rescheduled survey dates may result in additional fees and a scramble to find a new time. Surveyors have oftentimes already made travel arrangements and the coordination at AAAHC only becomes more difficult. "Disasters occur, a tornado damages a center or a key person leaves the staff, but as much as possible avoid rescheduling," says Mr. Grundman.
5. Fragmented groundwork. Surgery center leaders, such as administrators of directors of nursing, are often accustomed to juggling responsibilities and taking the lead. "We see a lot of administrators or DONs carrying the whole load of accreditation preparation," says Mr. Grundman.
While it is helpful to have team leader, one person shouldering the entire responsibility leaves the rest of the organization unaware. Accreditation surveyors will be speaking to more than just the administrator or DON during their visit. The language of accreditation is sometimes foreign to staff members that have not been through the process before. It is helpful to have the entire staff familiar with the process and prepared to work with surveyors.
6. Gaps in communication. Accreditation surveys occur once every three years. During that period, turnover and reassignment of duties is common. As the passing of the torch occurs and accreditation becomes someone else's key responsibility, critical information can be lost.
"Continuity is one of the biggest challenges. The organizations that do well have a stable team," says Mr. Grundman. Even if the team cannot remain the same, successful centers will focus heavily on communication. The new team will ask the old questions if necessary and regularly refer to AAAHC educational resources to stay up-to-date.
7. Absence of proper orientation for survey team. An orientation team to greet the survey team and introduce them to the facility helps the entire process go smoothly. A room with electrical outlets for lap tops and a door for private discussions gives surveyors an area to work from and demonstrates forethought. The survey team will initiate the orientation process by asking to tour the facility and speaking with key players, but it helps to have the organization reciprocate. Everyone involved becomes more comfortable with the situation.
Part of the orientation team's responsibility is to ensure that the surveyors know the cultural norms of the facility, whether spoken or implicitly understood. If there is a no smoking policy for the building's campus, let surveyors know so they do not inadvertently violate such norms.
The orientation team is encouraged to demonstrate what makes their surgery center different. If there is a specific patient population served at the center, unique equipment or specially trained staff the surveyor wants to know. "Share with us what makes the organization shine. We want to make sure we give centers credit for everything that they do," says Mr. Grundman.
8. Sparse documentation. Quality patient care and lower infection rates are hallmarks of ambulatory surgery centers and areas that accreditation surveyors zero in on. Daily practice in ASCs is rarely an issue, but a lack of evidence and proper documentation can be. AAAHC tools and preparation materials supply the list of documents ASCs need to have for accreditation surveys.
9. Lack of preparation. Each of the top accreditation mistakes made can be in some way traced back to a lack of preparation. When working with the handbook, leaders not only need to use the correct edition, but also plan accordingly. Which chapters apply? How can this information be shared with everyone in the center?
AAAHC offers self-assessment tools, designed to help centers to eliminate any element of the unexpected during an accreditation survey. "We tell organizations that this is an open book test. There is no reason not to do well," he says.
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