Raymond Grundman, the chief business development officer with the Accreditation Association for Ambulatory Health Care, specified the six areas the accreditation association wants ASCs to focus on in 2017.
1. Credentialing, privileging and peer review. Credentialing, privileging and peer review are three separate but interrelated processes:
- Credentialing validates a provider’s qualifications to offer healthcare services.
- Privileging is the process of governing body approval for a provider to deliver specific treatments, procedures or to use specific equipment.
- Peer review is the process of confirming a provider's ongoing competence by enlisting similarly licensed others to review clinical records and other aspects of care, such as infection rates, compliance and patient satisfaction surveys.
Surveyor comments associated with deficiencies for these processes include:
- Peer review not being incorporated into the reappointment process;
- Delineation of privileges for specific procedures or use of specific equipment;
- Appropriate primary or secondary source credentials verification were not performed.
2. Documentation. Requirements for documentation appear throughout the standards.
Often, an organization has a process to meet standards requirements, but the process's follow-up doesn't written documentation when it should. Two specific areas frequently cited are allergy documentation and written evaluation of scenario-based emergency drills.
3. Safe injection practices and medication safety. Multiple standards related to safe injection practices and medication safety had high levels of deficiencies last year . Proper storage and use of multi-dose vials and recall policies topped the list.
4. Staff education and training. An important part of maintaining and improving quality and safety is staff education and training. When new staff and providers join the organization, national guidelines change, so staff and providers need sessions to remember/reinforce what they once knew. Training must be sufficiently frequent to ensure staff and providers are up-to-date.
Surveyor findings regarding non-compliance included the failure of physicians to participate in infection prevention and safety training.
5. Quality improvement program. Part of being a high-performing and accreditable organization is showing a commitment to continuous improvement. A well-organized quality improvement program and documentation of effective quality improvement studies are key elements.
The deficiencies here are strongly associated with the lack of or inadequacy of a measureable, quantifiable performance goal. To ensure that the goals meet the requirements, they should be specific, measureable, achievable, relevant and time-bound.
6. Performance maintenance of standards with high compliance. The highest compliance findings (100 percent rated substantially compliant) indicate that AAAHC-accredited organizations:
- Provide patients with the opportunity to participate in decisions involving their health
- Engage healthcare professionals who consistently practice their professions in an ethical and legal manner
- Provide information to patients regarding fees for services and payment policies
- Have implemented fiscal controls for rates and charges
- Achieve consistency in documentation regarding the person responsible for the patient’s care
- For Medicare Deemed Status surveys, there was strong overall performance with regard to over 200 specific AAAHC/Medicare standards.
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