When managed appropriately, accreditation can be a business-enhancer for ambulatory surgery centers. It helps centers stay on track where it concerns quality and safety, and it reassures patients that they are seeking treatment in the right place.
However, mismanaged accreditation is quite common. Documentation in particular is problematic for ASCs, causing problems related to accreditation readiness, compliance with state and federal regulations, ability of providers to practice and patient safety, among other things.
1. Accurate credentialing. Credentialing is the number one accreditation problem for ASCs, and with good reason. The process is involved and requires strict adherence to documentation and deadlines. Having a single person responsible for coordinating credentialing is one way to cut down on the potential for credentialing miscommunications that may lead to failed accreditation surveys.
2. Up-to-date documentation for patients. Documentation must be updated at every opportunity. This is particularly problematic for documentation of patient allergies and sensitivities. Even if there is nothing new to be recorded, the attending provider must make a note of this in the patient's record.
3. Up-to-date documentation for staff. The corollary to updated patient documentation is updated staff documentation. If a staff member receives continuing education credits, they must be documented. If a staff member adds or loses privileges, this must be documented.
4. Outdated accreditation handbooks. This is an easy way to have an accreditation survey go wrong — very wrong. While accreditation readiness is a continuous process, before consulting the accreditation manual for the formal process, ensure it is the one for the correct accreditation. All accreditation organizations for ASCs have a standardized process for which year's book should be used. Identify where you accreditation falls within this timeline, and if a new book is necessary, request one from the accrediting body.
5. Changes in quality data reporting from CMS. CMS recently changed its quality data reporting requirements, which can be confusing for ASCs, especially when it seems the new reporting requirements do not apply. They do, in fact, apply, even if the ASC must report zero volumes. For those who are resistant to changing workflow to better collect data, note it is a matter of accreditation and can be conveniently integrated into the process.
6. Documentation of infection control processes. Even if an ASC has the best infection control program there is, it will all be for naught without documentation. A documented risk analysis and documentation of infection risk reduction for surgical sterilization are key.
7. Medication handling and storage. Look-alikes, sound-alikes and expired medications are all culprits here. There are specific regulations for storing medications that have the potential to be swapped accidentally. Be sure these are followed. In addition, be aware of proper pathways for the disposal of expired medications, when the time comes. Also be aware of single- versus multiple-use medications and their respective regulations where it concerns patient safety.
8. Emergency preparedness and staff training. All ASCs must have an emergency preparedness plan. Emergencies include natural disasters, loss of ASC functions, armed intruders and other scenarios. Find a plan that follows state and federal regulations for disaster preparedness, customize it to your ASC, and inform your staff of their potential responsibilities during a disaster. Also, practice the plan — hold and document regular emergency drills.
9. Preparation. As mentioned above, accreditation is a year-round activity. Don’t let it take your center by surprise. Be methodical and purposeful in scheduling your accreditation, preparing for it and involving the team in any relevant accreditation processes. While accreditations can be rescheduled, moving the date may result in extra fees and changed survey requirements (potentially including the use of a different handbook).
10. Survey team orientation. On the big day it's important to start things out right. Developing a rapport with the accreditation team and giving them the resources they need to do their job are very important. Introduce them to staff, give them an adequate workspace and be prepared to answer any questions or show any documentation as the need arises. This will make the accreditation process flow smoothly.
For a list of the most common accreditation mistakes from The Joint Commission, the Accreditation Association for Ambulatory Health Care and the American Association for the Accreditation of Ambulatory Surgery Facilities, click here.
More Articles on Accreditation:
5 Steps to Safer Injections
What Are the Top Root Causes of Surgical Sentinel Events?
Accreditation Tip: 15 Best Practices to Prevent SSIs
However, mismanaged accreditation is quite common. Documentation in particular is problematic for ASCs, causing problems related to accreditation readiness, compliance with state and federal regulations, ability of providers to practice and patient safety, among other things.
1. Accurate credentialing. Credentialing is the number one accreditation problem for ASCs, and with good reason. The process is involved and requires strict adherence to documentation and deadlines. Having a single person responsible for coordinating credentialing is one way to cut down on the potential for credentialing miscommunications that may lead to failed accreditation surveys.
2. Up-to-date documentation for patients. Documentation must be updated at every opportunity. This is particularly problematic for documentation of patient allergies and sensitivities. Even if there is nothing new to be recorded, the attending provider must make a note of this in the patient's record.
3. Up-to-date documentation for staff. The corollary to updated patient documentation is updated staff documentation. If a staff member receives continuing education credits, they must be documented. If a staff member adds or loses privileges, this must be documented.
4. Outdated accreditation handbooks. This is an easy way to have an accreditation survey go wrong — very wrong. While accreditation readiness is a continuous process, before consulting the accreditation manual for the formal process, ensure it is the one for the correct accreditation. All accreditation organizations for ASCs have a standardized process for which year's book should be used. Identify where you accreditation falls within this timeline, and if a new book is necessary, request one from the accrediting body.
5. Changes in quality data reporting from CMS. CMS recently changed its quality data reporting requirements, which can be confusing for ASCs, especially when it seems the new reporting requirements do not apply. They do, in fact, apply, even if the ASC must report zero volumes. For those who are resistant to changing workflow to better collect data, note it is a matter of accreditation and can be conveniently integrated into the process.
6. Documentation of infection control processes. Even if an ASC has the best infection control program there is, it will all be for naught without documentation. A documented risk analysis and documentation of infection risk reduction for surgical sterilization are key.
7. Medication handling and storage. Look-alikes, sound-alikes and expired medications are all culprits here. There are specific regulations for storing medications that have the potential to be swapped accidentally. Be sure these are followed. In addition, be aware of proper pathways for the disposal of expired medications, when the time comes. Also be aware of single- versus multiple-use medications and their respective regulations where it concerns patient safety.
8. Emergency preparedness and staff training. All ASCs must have an emergency preparedness plan. Emergencies include natural disasters, loss of ASC functions, armed intruders and other scenarios. Find a plan that follows state and federal regulations for disaster preparedness, customize it to your ASC, and inform your staff of their potential responsibilities during a disaster. Also, practice the plan — hold and document regular emergency drills.
9. Preparation. As mentioned above, accreditation is a year-round activity. Don’t let it take your center by surprise. Be methodical and purposeful in scheduling your accreditation, preparing for it and involving the team in any relevant accreditation processes. While accreditations can be rescheduled, moving the date may result in extra fees and changed survey requirements (potentially including the use of a different handbook).
10. Survey team orientation. On the big day it's important to start things out right. Developing a rapport with the accreditation team and giving them the resources they need to do their job are very important. Introduce them to staff, give them an adequate workspace and be prepared to answer any questions or show any documentation as the need arises. This will make the accreditation process flow smoothly.
For a list of the most common accreditation mistakes from The Joint Commission, the Accreditation Association for Ambulatory Health Care and the American Association for the Accreditation of Ambulatory Surgery Facilities, click here.
More Articles on Accreditation:
5 Steps to Safer Injections
What Are the Top Root Causes of Surgical Sentinel Events?
Accreditation Tip: 15 Best Practices to Prevent SSIs