As the outpatient surgery market continues to flourish, the accreditors for ambulatory care continue to expand their products and services to meet new patient care needs. As you'll see in this update, the AAAASF, AAAHC and JCAHO are also working together more via various collaborative and legislative efforts to protect the needs of this emerging market.

AAAASF not just for offices
The American Association for Accreditation of Ambulatory Surgery Facilities continues to expand its scope of services beyond office-based surgery accreditation. The AAAASF now accredits many different types of surgical and medical specialty ambulatory facilities, in addition to multi-specialty facilities. The AAAASF is expanding its board to represent more specialties, recently adding an orthopedic surgeon and a DO in urology. The accreditor is also looking to add a dermatologist, podiatric surgeon and a public member, as well as other untapped specialties, says AAAASF President James Yates, MD.

"The public is waking up to the fact that we are a more significant player in this field," says Dr. Yates.

• Getting involved with legislative action. The AAAASF's executive director and legislative team have been traveling across the county, pushing for various efforts to protect the rights of and to critique legislation governing ambulatory surgery centers and office-based surgery centers, says Dr. Yates. "Many states are now calling us to help them plan how to oversee office-based surgery centers and what standards they should use," he says.
• Widening the inspector pool. The AAAASF is working to recruit more retired physicians and surgeons to conduct its triennial inspections. "We have fanned out to ASCs and every specialty organization to see if they have any physicians who want to stay in the game as a surveyor," says Dr. Yates. "Our retired inspectors are among our best."
• Intact standards. AAAASF has revised its standards four times since 1985, but for the most part, the intentions and requirements have remained intact. Perhaps the most noteworthy revision concerned propofol, which AAAASF says must be administered by an anesthesiologist, CRNA or anesthesia assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under direct supervision of an anesthesiologist. The AAAASF still demands 100 percent compliance.
• Creating a consulting arm. AAAASF board member Geoffrey Keyes, MD, created a Web-based program (www.surgimetrix.com) that helps surgery centers manage all types of compliance issues. SFR (Surgery Facilities Resources, Inc., a subsidiary of AAAASF) is marketing this program. SFR plans to offer overall consulting for ambulatory care professionals. SFR (www.surgeryfacility.com) is also facilitating accreditation to overseas surgical facilities, says Dr. Yates.

AAAHC making standards more user-friendly
The Accreditation Association for Ambulatory Health Care revised and added some new standards for 2007, but most of its changes center around dividing some of the ancillary chapters in its accreditation handbook to give more clarity for the wide variety of outpatient facilities it accredits. Last month, the AAAHC posted its draft standards for review at www.aaahc.org for a 30-day comment period. The accreditor will vote on the standards the weekend of Nov. 3 and will release the new handbook by the end of February. Here's a rundown on what's new:

• Easier to read when broken into two. Standard V in Chapter 9 (Anesthesia Services) is a long statement that covers providing sedative, hypnotic or analgesic drugs. Though the language won't change, the AAAHC will cut this standard into two (new standards W and X) to make the requirement easier to understand.
• Adding appropriate new technology. Chapter 17 (Diagnostic Imaging Services) has changed considerably. Refer to www.aaahc.org; the new text is underlined and the old text is struck through. For starters, AAAHC added new technology (ultrasonic) that is appropriate for imaging services. Standard C (requiring radiologists to authenticate examination reports except those for specific procedures) is broken into three components in a checklist approach for facilities to more easily understand. To provide imaging services and analyze imaging test results, organizations must have the appropriate training and credentials, be granted privileges to provide the services, and undergo appropriate safety training and provide services in a safe manner.
• Clarifying the different components of health education and wellness. AAAHC split Chapter 24 (Health Education and Wellness) into areas for those that offer health education and promotion and for those that perform comprehensive health education and disease prevention programs. This division reflects how various surgery centers operate so that organizations can figure out which requirements apply to them, says Meg Gravesmill, the AAAHC's director of accreditation services.

Standards A through G apply to all health education and health promotion services, while standards H, I and a new J apply to comprehensive health education and disease prevention programs.

Standard H is newly formatted to discuss health education and promotion programs that are based on a complete needs assessments. The standard covers four specific needs: relevant health risks and health education needs, using data sources in the assessment, quantifying risk whenever possible and using data to direct the programming.

Standard I is a combination of most of the components from the old Standard H, in addition to taking from Standard C topics to be considered in programs that include disease-specific screening and educational programs. The new standard J says that health education and promotion programming should be an integral component of quality improvement activities.

Chapter 5, Quality Management and Improvement, Subchapter II (Quality Management Program), details the quality improvement studies that facilities must complete. An updated Appendix E at the back of the handbook will add user-friendly tips about the purpose of each specific step.

"Some may not fully understand all the steps for an appropriate QI study and make the studies harder than they are," says Ms. Gravesmill. "If you're not familiar with all the steps and don't know what the studies are, it may be a difficult concept to grasp."

• Working with the states on accreditation issues. As with the other accreditors, the AAAHC is working with various states to help promulgate standards for accreditation. The states appreciate the guidance, as there are so many different models in outpatient treatment today, says Carolyn Kurtz, the AAAHC's director of government relations.

JCAHO mulls performance measures

• National Patient Safety Goals. The Joint Commission on Accreditation for Healthcare Organizations added a new goal for 2007 (Goal No. 13, which was released July 1, but takes effect in January) that requires organizations to encourage patients' active involvement in their own care. Ambulatory organizations must also define how patients and their families report concerns about safety and encourage them to do so.

JCAHO had already created an Accreditation Participation Requirement that addresses giving patients opportunities to register complaints, says Michael Kulczycki, MBA, CAE, the executive director of the Joint Commission's Ambulatory Care Accreditation Program. APR No. 8 requires you to encourage individuals to contact JCAHO if they have concerns about patient care and safety that you haven't been able to resolve with them.

Provision of Care standard 6.10 also requires organizations to educate patients about basic health practices and safety and medical equipment.

"In my mind, that sets the connection that surgery organizations have already been doing this," says Mr. Kulczycki. "It's just formalized in a goal to bring more attention to it."

Keeping those existing goals that challenge facilities on the roster, such as the medication reconciliation requirement throughout the continuity of care (No. 8), will give you more time to create better systems and thus comply with the goal, says Mr. Kulczycki. JCAHO clarified language in Goal No. 8 to make clear that caregivers give patients the complete list of medications they take when discharged.

"In the ambulatory environment in particular, the continuity of care piece is not a formal handoff," says Mr. Kulczycki. "The spirit of this allows the next provider of care to know what medications the patient takes."

Additionally, the clarification stresses that the patient is the conduit and must take that list of medications to his next provider. "Organizations share the information with the patient, and it's the patients' responsibility to share that information with the next provider," adds Mr. Kulczycki. "That is not our expectation of the caregiver in a freestanding ambulatory setting."

• Disaster privileging and assessing competence for non-employees. JCAHO spells out for both licensed independent practitioners and other staff disaster privileging processes via HR 1.10, which requires organizations to offer qualified staff appropriate to the method of care treatment. The standard's elements of performance, for example, make clear that staff trained in emergency equipment use and cardiopulmonary resuscitation through an evidence-based training program are available to patients. This obligation applies to Medicare-certified ASCs only.

A revision to one of the elements of HR 1.20 states that, before giving care, organizations assess the qualifications and competence of a non-employee that an LIP brings to the organization to ensure it's within the scope of the services she provides. For example, if an orthopedic surgeon brings an orthopedic nurse to the facility to assist with a procedure, you must perform a competence check on the nurse with respect to the functions that she'll perform, says Mr. Kulczycki.

If a physician brings in someone to aid him and there's no matching staff (employee) position, consult professional association guidelines for what credentials the person should possess as well as in the competence, says Mr. Kulczycki.

• Introducing performance measurements for ambulatory care. JCAHO is working with the National Quality Forum on a three-year project to investigate what performance measures to use for non-acute settings. The NQF is seeking feedback on the issue from ambulatory care associations and specialty groups through its Web sites. The "ASC Quality Collaborative" will dovetail into this project, an effort among AAASC and FASA, the ambulatory accrediting bodies and major corporate surgery organizations to try to get ahead of the curve, says Mr. Kulczycki. "We're looking at what measures are routinely used in the surgery center environment and how we can reach a consensus on these measures." These collaborative measures will then be submitted to NQF for consideration as part of their approval process for non-acute care measures for "specialty providers."
• Initiating a standards overhaul and revision. The Joint Commission this month launched a standards improvement initiative for its ambulatory care, office-based surgery, hospital, critical access hospital and home care programs to assess all of its standards for relevance with today's healthcare practices. The accreditor will delete unnecessary standards and requirements and consolidate other standards. For example, performance improvement efforts are often duplicated in standards that cross over into the infection control, environment of care and leadership chapters, says Mr. Kulczycki. This effort will engage customers from each of the accreditation programs in significant ways to help guide the process, resulting in completely revamped standards to be introduced in late 2008 for accreditation services in 2009.
• Issuing an accreditation manual just for ASCs. JCAHO this month will release a paperback version of standards specific to ASCs. It will remove all standards that don't apply to this setting and adjust some language for clarity.
• Recognizing lessons learned from the unannounced survey process. The Joint Commission this year switched from regularly scheduled triennials to unannounced surveys, which still fall within the parameters of every three years. New Joint Commission ambulatory care customers' first surveys continue to be planned. For those centers subject to a resurvey with an annual surgery volume of 1,500 cases or fewer that are subject to resurvey, the Joint Commission will give five days' notice. Organ-izations have told the Joint Commission that the unannounced survey process has given surgery center leaders the opportunity to change the culture to constant survey readiness, says Mr. Kulczycki.