• An Insider’s Guide to ASC Accreditation

    By Nancy Thomas, MD, Academy Representative on the AAAHC Board of Directors

    This article is from September 2007 and may contain outdated material.

    Today, more than 95 percent of cataract and lens procedures are performed in an ambulatory setting, making them the United States’ No. 1 outpatient surgical procedure. Up to 70 percent of U.S. Academy members work in ambulatory surgical centers and, reflecting a growing trend, about 30 percent own their centers.

    The Academy recently became a member organization of the Accreditation Association for Ambulatory Health Care (AAAHC). As the Academy’s first representative on the AAAHC’s board of directors, I can attest to accreditation’s value for assuring the public, licensing agencies and payers that ASCs are complying with the highest standards of patient care. And as an AAAHC surveyor for more than a decade, I am committed to the value that the process offers to our profession (see “What’s in It for You”).

    Key to this process is the survey, when AAAHC surveyors visit the ASC.

    What to Expect

    AAAHC surveys are not mere inspections—they also are meant to be educational. Surveyors are your peers; they include experienced physicians, registered nurses and administrators. Throughout the process, surveyors work with you to assess how your policies and procedures compare to the quality standards of similarly structured ASCs. Depending on your ASC’s size and types of procedures performed, a survey can take from one to a few days to complete by one or more surveyors. The fees for an accreditation survey begin at $3,000 for an office-based practice and can increase based on the scope of services that your organization provides.

    The bulk of your work is completed with the Application for Survey, which requests specific, in-depth information about your ASC. Your application outlines how your organization fulfills AAAHC standards in different areas of compliance, and there’s no one “right” answer. For instance, you may meet employee and occupational health standards by outsourcing all the relevant functions, or you may offer tuberculosis testing and hepatitis B vaccines while outsourcing other functions, such as ergonomic training. Another example is Material Safety Data Sheets—you may keep a book of these whereas others use a toll-free number.

    After your survey, the AAAHC will ask the surveyors if your presurvey materials matched what they observed.

    How to Prepare

    When completing your AAAHC Application for Survey, you may find it useful to review the Self-Assessment Manual and the Accreditation Handbook for Ambulatory Health Care, available for purchase from the AAAHC. It’s also a good idea to conduct your own mock survey, which prompts reassessment of your accreditation standards compliance and ensures that your staff understand the survey process. You’ll find that AAAHC staff are open to questions throughout the process.

    For a fee, you can ask the AAAHC to provide a consultative survey prior to the “real” survey. The AAAHC also offers classes, books and consulting services to help you prepare for the survey. It has a separate, independent subsidiary—Healthcare Consultants International—that provides formal consulting services, and many other national consulting services are also available.

    When the Surveyor Arrives

    Appoint a single survey liaison at your ASC—the captain of the ship—who should plan to accompany the surveyor and answer questions throughout the survey. All staff should be comfortable discussing how your facility complies with accreditation standards in their area of expertise. Generally, surveyors speak with as many different people as they can. Other helpful tips include:

    • Provide a work area for your surveyor. This should be equipped with a table or desk and electrical outlet for the surveyor’s laptop. Stock the space with your procedural manuals, charts for review and personnel files.
    • Pull your records. Be prepared to present your financial records, minutes of committee meetings, credentialing files, narcotics log, waste log and surgical log (you will see a complete list of what’s required in your application form).
    • Organize documentation by type. The survey process will be faster if different types of documents are compiled in separate books, including one for contracts, one for preventive maintenance records, one for licenses and inspections, and so on. Surveyors often check how often your generator is refueled, for instance, and whether your logs correspond with weekly caseloads.

    Surveyor as Your Advocate

    Your surveyor, as the fact finder, will report to the AAAHC on your level of standards compliance. Your efforts will be assessed at one of four levels for each standard: substantially compliant, partially compliant, noncompliant or nonapplicable.

    Prior to leaving the premises, your surveyor will conduct a summation conference where he or she will discuss the initial findings with your liaison and other members of your team. Any area that’s assessed below substantially compliant will be specifically noted so that you can correct any possible miscommunications. You will typically receive a final report in a couple of months, with the decision as to whether you have been awarded accreditation for three years, one year or six months—or, possibly, a deferral or a nonaccreditation. If, when you study the report, you find discrepancies, there is a procedure for appeal.

    There is no such thing as perfect, so don’t be disappointed if you don’t meet every mark. Focus instead on continuous compliance.

    Accreditation: What’s in It for You?

    The AAAHC provides peer-based accreditation that’s meaningful to the public as well as to the Centers for Medicare and Medicaid Services, other insurers and state licensing agencies. It accredits more than 3,000 ambulatory health care organizations, and more than half of those are ASCs. Out of the more than 1,600 ASCs currently accredited, approximately 250 are single-specialty ophthalmology surgery centers. Through the accreditation process you will gain:

    • An accreditation certificate—a public symbol of your commitment to provide high-quality health care.
    • A team focus on common objectives to improve the quality of care, which can motivate your staff to excel and grow.
    • A head start toward advancing your practice to the next level, by creating a template for reviewing, recording and documenting your practices.
    • Accreditation news and resources—these include tools to help you promote your accreditation at the local level and learn more about state laws and regulations.
    • Access to learning and networking through the Achieving Accreditation seminars that the AAAHC offers four times a year.
    • Access to AAAHC Institute reports—AAAHC-accredited organizations can participate in and have access to a wealth of benchmarking and patient satisfaction studies conducted by the AAAHC’s Institute for Quality Improvement. Study findings can enhance your services by helping you better meet standards put forth by the AAAHC and better understand how patients experience care.

    For more information, visit www.aaahc.org.

    Troubleshoot Now

    Start with a comprehensive review of your general information. For example, when your application asks if any staff members have been named in, or are the subject of, a malpractice suit within the last four years, it means at your ASC as well as anywhere else your people practice.

    In my experience, ophthalmology ASCs most frequently encounter problems in the following areas:

    • Patient rights. These need to be followed to the letter of the law. For instance, some states ask that the state medical board phone number be posted.
    • Governance. Does your ASC feature a governing body with ultimate authority and full legal responsibility over all aspects of your facility’s operational management? The AAAHC surveyors will want to see your bylaws that outline the governing body’s duties and responsibilities, and meeting minutes to monitor its actions. Your facility’s leaders should have documented approval of a budget, service contracts and other operating details at an annual meeting.
    • Personnel files. Ensure your personnel files are in order. By federal law, they are required to contain I-9 forms.
    • Credentialing. Verify documents presented by your health care professionals (you can reference the AMA’s master file). Surveyors will expect the governing body to have approved a list of privileges for each practitioner.
    • Peer review. Credentialing and privileging applications for appointments and reappointments must have a peer- review element that’s demonstrable for Eye M.D.s and anesthesia personnel.
    • Reportable conditions. Your ASC ought to have a formal policy to notify public health authorities of reportable conditions. Your surveyor will want to see this policy.
    • State and federal laws. The AAAHC accreditation standards elaborate on what’s mandated by the CMS or state licensing authorities, so knowledge of legislative requirements is helpful.