Pass Your Accreditation Inspection with Flying Colors

Preparing for an accreditation can be a morale-boosting, team-building, educational process for your facility. Here's some advice on how to prepare and how to make the inspection day go smoothly.

If you're facing an accreditation survey, you've probably realized that it's a full-time job to get your facility and staff into the tip-top shape that the accreditation agencies require. But preparation need not be onerous - if you involve your staff and take the time to examine the reasons behind the requirements, you can turn the entire process into a team-building, educational, morale-boosting experience for your facility.

Through my experience as a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC), chairman of the standards committee for the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF), an adviser for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and a surveyor for 130 surgery centers, I've learned a lot about the accreditation process, and I've seen the best and worst of how surgery facilities handle them. In this article, I'll share my tips on how to prepare for an inspection, no matter which agency you choose (see sidebar), how to make the inspection itself go smoothly, and how to make the process a positive experience.

Get Prepared
The safest way to prepare is to go through the standards manuals section by section to determine your current level of compliance and what you need to change to come up to standard. Don't attempt to tackle this mammoth task on your own - establish which staff member can best handle each section, divvy up the work, assign timelines to each task, and set a meeting time to revisit each section as a group. Surveyors can focus on any of the standards, but here are some of the most important things to have ready:

Have all your documentation organized and available: The surveyor can ask to scrutinize almost any piece of documentation, so it's important to make sure it's organized, legible, complete, up to date, and easily available.

I always ask to see patient charts first - I consider them to be a good tip-off as to what's happening in the rest of the facility. Unwarranted uses of abbreviations, crossouts, blank spaces, and a sloppy chronology of the record send up a red flag.

Other types of documentation that must be in order include: policy and procedure manuals; personnel files, including staff innoculation records (for hepatitis B and tuberculosis); physician licensure and credentialing records; transfer procedures; quality assurance studies; patient exit surveys; vendor agreements; narcotics logs; medical education (CME) documentation; relevant licenses and permits; insurance documents; biomedical equipment calibration books; and minutes of the governing board meetings.

Most facilities have processes in place to keep their basic documentation in order. But there are some important functions that centers tend to ignore, or they have the processes in place, but never bother to document their activities. Here are a few:

Peer review processes:
Many facilities I've visited don't perform and document regular peer reviews of their surgeons. A surveyor will want to see that before you reappoint a surgeon (this usually happens once every two years), you make it a practice to review the surgeon's charts, look over patient satisfaction surveys, analyze complication rates, etc., to establish whether the surgeon really should be getting the same privileges.

Risk Management Protocols:
I've visited a number of centers that don't have risk management protocols in place, meaning they have no methods for following up on patient complaints, correcting medical errors, etc. Remember that any number of things can go wrong at your facility. Make sure you have a designated risk management expert to examine potential risks - these could include everything from dealing with a patient complaint to evacuating patients in a fire - and develop contingency plans for dealing with them. The risk management expert should also keep the staff updated on new risks and contingency plans at your staff meetings.

Walk-through drills:
A number of facilities do have contingency plans on paper, but they never actually walk through the drills, so they don't know if their plans would work in a crisis. Two examples: I once visited a facility that was located on the 13th floor of an office building. I asked the facility manager how the staff would evacuate a patient in an emergency situation. She had a ready answer: There was a helipad on the roof of the building, she said, and if an emergency arose, they could fly the patient to a local hospital. The plan sounded great - on paper. When I asked her to physically walk me through the process, however, she could not locate the key to the door to the stairway that led to the roof. She found the key after some searching, and we continued the walk-through - only to find that there was no way that the staff could maneuver a stretcher - let alone a stretcher with a patient on it - up the spiral stairway.

Another time, I asked a facility manager to walk me through the protocol for caring for a patient with malignant hyperthermia. On paper, the facility had a procedure in place to treat the patient with ice and dantrolene. But nobody, including the anesthesiologist, knew where the ice or dantrolene was located. Don't be satisfied with paper drills. Chances are, once you walk through the steps, you'll discover weaknesses in your methods or find ways to improve them.

Confidentiality:
I've seen numerous instances where patient confidentiality is breached without the staff even being aware of the problem. For example, some facilities do not provide separate sign-in sheets at the front desk for their patients - they don't realize that allowing patients to see other patients' names is a breach of privacy. Some facilities do provide separate sign-in sheets, but they write the patients' names on a whiteboard in the pre-op area for all to see - another breach of privacy.

An additional confidentiality problem I often see is in pre-op staging areas that use curtains to divide the patient beds. Surgeons and staff often don't realize that the curtains do nothing to block out sound, and they often carry on private conversations with patients and their families, not realizing that they're completely audible to the person in the next bed.

Meeting minutes:
Many facilities have made regular staff meetings a part of their routine, but most fail to document those meetings. The surveyor wants proof that your staff communicates regularly, so make sure you document the time and date of all meetings, record who attended, and take notes on what was discussed and decided.

QA studies:
This is an area where I've seen facilities go overboard by doing too many studies that don't really mean anything. I once visited a center that boasted that it did 30 QA studies a month! Don't do quality assurance studies to prove yourself to an accrediting agency - do them to explore an issue that you truly need to explore. One of the most helpful types of studies is to document downtimes between cases, analyze how long it is taking your staff and surgeons to move from one case to the next, and find ways to shorten these periods. Another helpful study might be a supply usage study - if you have 10 eye surgeons using 10 different kinds of sutures, documenting the type of sutures used and the cost of each might give you a powerful tool to help convince the surgeons to use a standard variety. I think that performing four solid, useful studies a year will give you valuable insights into your facility and convince any surveyor that you are earnest about improvement.

Just some other thoughts on how to prepare:
Do a mock survey:
Once you think you have your "t"s crossed and your "i"s dotted, put on your surveyor's cap and walk through your center with a critical eye. Leave no stone unturned - check every cabinet, crash cart, drawer, and storage facility. Chances are, you'll come across areas you overlooked completely. JCAHO and AAAHC also offer test inspections, where, for a fee, you can have an inspector perform a mock inspection to prepare you for the official one.

Consider a consultant:
Several consulting firms guarantee that they will get you through an inspection. A consultant may make the process easier, particularly if it is your first inspection or if you had problems during a previous inspection. It's my opinion, though, that by the second inspection, you and your staff should be familiar enough with the process to handle everything on your own.

Take a class:
All three accreditation agencies offer educational sessions or workshops to help you prepare for inspections. Consider attending one, or send one or more of your staff.

The inspection day: making it run smoothly
Approach the day of the inspection as the culmination of your learning experience. Depending on the accreditation agency you choose, the surveyor will be a board-certified surgeon (all AAAASF surveyors are board-certified surgeons), a nurse, practice manager, anesthesiologist, or physician of any specialty. Remember that the surveyor is trying to help and educate, not find fault. Keep an open mind, do not get defensive under any circumstances, and consider the following suggestions:

Set up an area for the surveyor to work:
It's ideal if you can offer the surveyor a quiet area to review documentation, interview staff, and perhaps make phone calls back to the central office. It doesn't have to be an office - anything larger than a coat closet will do! Keep all the materials that the inspector will want to review in this area, and provide access to a phone.

Make your staff available:
You will choose the date of your inspection (unless it is an unannounced Medicare inspection), so on that day, make sure you are fully staffed - the surveyor wants to see how you operate on a "typical" day.

Have one of your staff members shadow the surveyor for the duration of the visit. This ensures that there is always someone available to answer questions, retrieve documents, find other staff, etc.

Make sure everyone attends the summation conference (I call this the "swipe and swap" meeting) at the end of the inspection, where the surveyor will present his or her findings and ask and answer any remaining questions. This meeting is also the last chance to correct or challenge the surveyor on what he/she found before it ends up in the written report to the accreditation committee.

Schedule multiple surgeries on the inspection day:
The surveyor will want to observe at least one surgery, so make sure you have multiple procedures scheduled in case you have a last-minute cancellation. I had one experience where the facility only had one surgery scheduled for the day, and the patient cancelled at the last minute. As luck would have it, however, one of the nurses had always wanted a rhinoplasty, and she volunteered to have her surgery on that day. So, I got to observe a surgery and the nurse got her nose done! I don't recommend you count on this, however - not many staff members will volunteer to have impromptu surgery to satisfy an accreditation requirement.

Keep the surveyor fair and square:
Beware of the surveyor who finds fault because he/she "doesn't do things that way." Remember that surveyors are trained not to personalize their evaluation. If a surveyor asks to see something that is not required in the standards, ask him to point out the requirement in the standards manual. Don't be afraid to ask if a request seems to be based on a surveyor's personal preference, and remember that even well-trained surveyors will sometimes lapse into "editorializing."

Once you get through the survey and receive your accreditation status (usually within three months) display your accreditation certificate with pride! Your facility has just undergone one of the most rigorous testing processes in the health care industry. You can move forward knowing that you are well prepared to handle the next inspection, well positioned to market your facility to new surgeons, patients, and the community, and most importantly, well equipped to continue to provide excellent patient care.

Accreditation Agencies

Accreditation is more than the "Good Housekeeping Seal of Approval" for surgery centers-this once voluntary process has become part of the standard of care. For example, many managed care plans require that facilities that they do business with become accredited. Some surgical organizations are also strongly encouraging their members to get accredited-for example, the American Society of Plastic Surgeons is pushing to get all their members who own office-based facilities to get their facilities accredited within the next three years. Three agencies perform accreditations. They are:

The American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF): This organization was formerly the American Association for Accreditation of Ambulatory Plastic Surgery Facilities (AAAAPSF). It requires that facilities be 100 percent compliant with its set of standards. AAAASF only accredits facilities that offer procedures accepted by the American Board of Surgical Specialties-that means that if you offer dermatology, endoscopy, internal medicine, dentistry, or podiatry services, you cannot be accredited by AAAASF. To date, about 550 ASCs have earned accreditation. Surveyors are volunteers and must be board-certified in at least one of the specialties contained within the ASC. As with all the agencies, accreditation costs depend on the size of the facility and the number of specialties. The cost of an inspection ranges from $675 for a single-specialty, one-OR center to $3,700 for a multispecialty, multiple-OR center. Call (888) 545-5222 or visit www.aaaasf.org.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO): This organization accredits a range of ambulatory care facilities, including ASCs, rehab centers, dialysis centers, and dental clinics. It has its own set of comprehensive standards dealing with patient care, safety, medical records, infection control, etc. An organization does not have to be in full compliance with every standard to become accredited. Rather, the organization must demonstrate overall compliance with the full set of applicable standards. To date, JCAHO has accredited about 100 ASCs. Surveyors are full-time employees; they may be physicians of any specialty, surgeons, nurses, or administrators. The six classifications granted to facilities are accreditation; accreditation with recommendations for improvement; provisional accreditation (the facility meets a subset of standards during a preliminary evaluation and must undergo a complete survey within six months); conditional accreditation (the facility is not up to par on several counts and must achieve compliance within a stipulated time period); preliminary nonaccreditation (a decision subject to review); and nonaccreditation. JCAHO has been working to make the inspection process more user-friendly for ASCs by creating ASC-specific standards; it also plans to create an office-based surgery standards manual by early fall and will plan inspecting facilities based on those standards by January 2001. The cost of an inspection varies from $4,000 for smaller facilities to $10,000 for larger sites. Call (630) 792-5000 or visit www.jcaho.org.

Accreditation Association for Ambulatory Health Care (AAAHC): AAAHC focuses on ambulatory care organizations, including ASCs, single and multispecialty group practices, and health networks. It has accredited about 1,100 ambulatory facilities, but not all are surgery centers. The organization uses volunteer inspectors who are surgeons, nurses, administrators, and other professionals involved in ambulatory healthcare. AAAHC grants facilities one of five rankings: Three year accreditation; one year accreditation; six-month accreditation; deferred (the facility does not meet standards, but can request another survey within six months); and denial of accreditation. AAAHC is in the process of creating a for-profit subsidiary ????-??? Healthcare Consultants International-that will provide consultative services for inspection applicants. The cost of an inspection runs from $3,375 for a one- or two-OR single-specialty facility to around $9,675 for a large organization. Call (847) 853-6060 or visit www.aaahc.org.