Accreditation is an ongoing quality process for an ASC. While accreditation doesn't solve all ills, it does help surgery centers and other healthcare organizations put in place and maintain processes to ensure safe and efficient care. Some standards, however, are universally challenging. In particular, documentation requirements tend to catch ASCs unaware.
The following are five most-often incomplete tasks having to do with documentation updates from the top three accrediting agencies for surgery centers: the Accreditation Association for Ambulatory Health Care, The Joint Commission and American Association for the Accreditation of Ambulatory Surgery Facilities.
1. Credentialing and privileging. This standard is by far the most difficult for ASCs to meet and maintain, according to records from both AAAHC and The Joint Commission. Credentialing and privileging is an intricate and time-sensitive process, requiring careful recording of many details, depending on what providers are employed to accomplish at their surgery centers.
"We're finding that one of the issues with credentialing and privileging is leaving people out of documentation or not updating documentation," says Naomi Kuznets, PhD, senior director and general manager of the AAAHC Institute for Quality Improvement. AAAHC surveyor Jo Vinson, RN, BA, CASC says that while organizations may adopt credentialing and privileging processes from larger organizations, the bigger picture may obscure the little things — such as which procedures staff need privileging to perform on a daily basis. "A surgeon may have general surgery privileges, but sometimes his specific privileges get dropped from the documentation," she says.
At The Joint Commission, Executive Director of the Ambulatory Care Accreditation Program Michael Kulczycki says credentialing and privileging has been the top most-missed standard for the past 10 years. "It's obviously an important area for ASCs to get right," he says. "This standard has 33 items and requires attention to detail, because there are discrete steps involved, and if some steps are missed, so is the standard." Surveyor Virginia McCollum, RN, also notes the difficulty of the standard. "A day never goes by that I'm not talking to someone about it," she says. "ASCs have to hire someone to do this who is very, very organized. There are people who live that job, and they are to be cherished, because having the organization ability is what it takes."
2. Setting measurable benchmarks. Dr. Kuznets also says creating goals whose progress can be measured and documented is sometimes challenging for surgery centers. "If you don't set a measurable goal — and you have to measure performance against a goal — then it's pretty much impossible," she says. To improve goal-setting, she recommends organizations analyze just what it is they will need to accomplish using a benchmark before implementing the data collection process. Ms. Vinson adds that cursory reading of the standards can also sometimes contribute to confusion. "It seems like a very fundamental thing, but there can be erroneous understandings, misinterpretation of words and differential understanding of terms. If someone has been in the business a long time, incorporating changes to standards can also be challenging," she says. "Read them twice before you spend a lot of time addressing them."
3. Clinical record documentation updates. AAAHC records also show difficulty among ASCs in having updated documentation for patient visits, in particular, allergy documentation may suffer during follow-ups. This is a very important standard, with a simple enough fix in staff training.
4. Emergency drills. Document every emergency drill performed. In addition, document any problems and performance improvement plans. As in clinical documentation, note the planning and updates that occur for accreditation purposes, says Dr. Kuznets.
5. Look-alike, sound-alike medication documentation. According to Ms. McCollum and Mr. Kulczycki, proper documentation of look-alike and sound-alike medication is also a challenge for ASCs. This oversight can be particularly dangerous to patient safety.
The good news: ASC documentation challenges can be remedied. While it takes commitment, it is possible to achieve perfect compliance with these difficult standards. "ASC leaders have a lot on their plates. There are lots of expectations, but with leadership commitment and having the governing body commit to doing things right all the time, it goes a long way," says Mr. Kulczycki.
More articles on accreditation:
The ASC market by the numbers: A 2014 transaction primer
4 scripting opportunities to improve patient safety
Which item is most often left inside a surgical patient?
The following are five most-often incomplete tasks having to do with documentation updates from the top three accrediting agencies for surgery centers: the Accreditation Association for Ambulatory Health Care, The Joint Commission and American Association for the Accreditation of Ambulatory Surgery Facilities.
1. Credentialing and privileging. This standard is by far the most difficult for ASCs to meet and maintain, according to records from both AAAHC and The Joint Commission. Credentialing and privileging is an intricate and time-sensitive process, requiring careful recording of many details, depending on what providers are employed to accomplish at their surgery centers.
"We're finding that one of the issues with credentialing and privileging is leaving people out of documentation or not updating documentation," says Naomi Kuznets, PhD, senior director and general manager of the AAAHC Institute for Quality Improvement. AAAHC surveyor Jo Vinson, RN, BA, CASC says that while organizations may adopt credentialing and privileging processes from larger organizations, the bigger picture may obscure the little things — such as which procedures staff need privileging to perform on a daily basis. "A surgeon may have general surgery privileges, but sometimes his specific privileges get dropped from the documentation," she says.
At The Joint Commission, Executive Director of the Ambulatory Care Accreditation Program Michael Kulczycki says credentialing and privileging has been the top most-missed standard for the past 10 years. "It's obviously an important area for ASCs to get right," he says. "This standard has 33 items and requires attention to detail, because there are discrete steps involved, and if some steps are missed, so is the standard." Surveyor Virginia McCollum, RN, also notes the difficulty of the standard. "A day never goes by that I'm not talking to someone about it," she says. "ASCs have to hire someone to do this who is very, very organized. There are people who live that job, and they are to be cherished, because having the organization ability is what it takes."
2. Setting measurable benchmarks. Dr. Kuznets also says creating goals whose progress can be measured and documented is sometimes challenging for surgery centers. "If you don't set a measurable goal — and you have to measure performance against a goal — then it's pretty much impossible," she says. To improve goal-setting, she recommends organizations analyze just what it is they will need to accomplish using a benchmark before implementing the data collection process. Ms. Vinson adds that cursory reading of the standards can also sometimes contribute to confusion. "It seems like a very fundamental thing, but there can be erroneous understandings, misinterpretation of words and differential understanding of terms. If someone has been in the business a long time, incorporating changes to standards can also be challenging," she says. "Read them twice before you spend a lot of time addressing them."
3. Clinical record documentation updates. AAAHC records also show difficulty among ASCs in having updated documentation for patient visits, in particular, allergy documentation may suffer during follow-ups. This is a very important standard, with a simple enough fix in staff training.
4. Emergency drills. Document every emergency drill performed. In addition, document any problems and performance improvement plans. As in clinical documentation, note the planning and updates that occur for accreditation purposes, says Dr. Kuznets.
5. Look-alike, sound-alike medication documentation. According to Ms. McCollum and Mr. Kulczycki, proper documentation of look-alike and sound-alike medication is also a challenge for ASCs. This oversight can be particularly dangerous to patient safety.
The good news: ASC documentation challenges can be remedied. While it takes commitment, it is possible to achieve perfect compliance with these difficult standards. "ASC leaders have a lot on their plates. There are lots of expectations, but with leadership commitment and having the governing body commit to doing things right all the time, it goes a long way," says Mr. Kulczycki.
More articles on accreditation:
The ASC market by the numbers: A 2014 transaction primer
4 scripting opportunities to improve patient safety
Which item is most often left inside a surgical patient?