Welcome to the new Outpatient Surgery website! Check out our login FAQs.
Accreditation Roundup: What's in Store for 2004?
How the major accrediting bodies are changing their procedures and standards.
Outpatient Surgery Editors
Publish Date: October 10, 2007   |  Tags:   Accreditation

If you're already accredited or are planning to seek accreditation in 2004, it may help to understand what changes are coming your way. Here's what to expect from your accrediting body this year.

Get ready for tracer methodology
The main event in 2004 for ambulatory care organizations accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a new survey process called tracer methodology, which is part of the accrediting body's Shared Visions - New Pathways effort. With tracer surveys, JCAHO will focus less on policies and procedures and more on real-world patient experiences. "We're trying to help organizations make participation in accreditation a continuous operational improvement exercise, and much less of a contest for scores," says JCAHO.

During a tracer survey, JCAHO selects an open patient record - typically a low-volume, high-risk case - and follows the patient's entire experience through the facility. The result will comprise 60 percent of the facility's total outcome, although JCAHO will no longer issue scores. This new approach is a big change from the more traditional "boardroom" chats between organization leaders and JCAHO, but some say it's more rational. "It makes more sense than a surveyor suddenly saying, 'Let's take a tour of your building,'" says Gary Rippberger, DPM, the administrator of HealthSouth Surgery Center of Hawthorn in Libertyville, Ill., which served as a pilot center for JCAHO in September. For leaders, he says, the tracer approach will be more understandable and easier to sell to staffers since everything the surveyors ask is related to the patient's chart and follows the same sequence as the usual process of care.

Still, Dr. Rippberger and his staff did learn a few things from the pilot survey that may help you prepare for a similar survey at your facility:

  • Know how you handle low-volume/high-risk cases. The staff is less apt to be prepared in these situations, says Gina Dolsen, HealthSouth's regional quality coordinator for the Chicago region and Ohio. "Cataracts are different since you tend to perform them all the time," she said. "But if you perform one pediatric dental case in six months, the staff may not be as prepared to discuss this process." During the HealthSouth pilot survey, the JCAHO surveyor selected just that: A pediatric dental case.

    Throughout the pilot survey, the surveyor walked through the facility, asking caregivers about their roles in treating this patient - all the while evaluating the core accreditation issues of medication management, infection control (IC) and data collection. For example, when assessing IC compliance, the surveyor asked: "How did you clean the room following the case?" Says Ms. Dolsen: A dental case is considered "dirty," and the surveyor wanted the staff to discuss the cleaning process in detail. The surveyor also asked how the staffers handled pediatric concentrations of various medications.

  • Prepare physicians. As part of the tracer surveys, JCAHO will involve physicians more than ever before. During the HealthSouth pilot survey, the surveyor asked the anesthesiologist about the minimum requirements for a history and physical (H&P), whether the facility complies with JCAHO's requirements for H&Ps, who co-signs them and whether the organization followed the state law for H&Ps, according to Ms. Dolsen.
  • Educate and train regularly. Facility leaders must educate their staffers daily on the new survey process so they can become attuned to it, says Ms. Dolsen. "I may know all the answers as a regional coordinator, but what's important is that I train everyone on a daily basis," she adds. At HealthSouth Surgery of Hawthorn, the staff met during quality-assurance meetings to discuss not only patient-safety and PI issues, but patient-flow issues as well. They discussed what happens from prepping to anesthesia to the actual procedure, to transfer to the post-operative care unit, all the way through to post-discharge follow-up calls and visits. This will also help your facility prepare for JCAHO's unannounced surveys, scheduled to begin in 2006.

Dr. Rippberger says his experience with the tracer approach has helped the entire staff view accreditation as an ongoing process, not as an isolated test they need to pass so they can get back to the practice of patient care. "You look at the tracer process in the view of not just improving small components of your systems, but in looking at the entire system from top to bottom with patient safety in mind," he says.

In all, says Dr. Rippberger, the whole experience has helped everyone in the facility realize that there's always something they can do to improve patient care. "Never accept that what you are doing is the best way," advises Dr. Rippberger. "There's always room for improvement no matter how well you think your system works."

Prepare for new standards
The big news for Accreditation Association for Ambulatory Health Care (AAAHC) accredited organizations is new 2004 standards. The biggest changes include clarification of the requirements about post-op physician availability and additional guidelines for facilities that perform "invasive" procedures. Here are some highlights:

  • Post-op availability. AAAHC clarified its previous requirement that a physician or dentist must be present or "immediately available" until all patients operated on that day are physically discharged. The standard now requires the physician or dentist to be present or "immediately available" until the medical discharge of the patient. Medical discharge refers to the release of a patient after clinical recovery from surgery and anesthesia, says Beverly Philip, MD, the chairperson of the AAAHC's Standards and Survey Procedure Committee. The new standard also requires personnel qualified in advanced resuscitative techniques to be "present or immediately available" until the patient is physically discharged, and says that at least one physician or dentist must be present or available by telephone when patients are still in the center. AAAHC hopes the new standard will give physicians greater flexibility and even reduce costs while ensuring proper patient care.
  • Invasive-procedure standards. The AAAHC grew its list of invasive procedures to include pain management, endoscopy, lithotripsy and in vitro fertilization. Facilities performing these procedures must now adhere to the same equipment-handling, supply-maintenance and other standards previously reserved for just a handful of other procedures. "We have it now in writing in case there are any questions," said Adrian Hochstadt, the AAAHC's director of public affairs.
  • Laser safety. The AAAHC created new, more detailed laser-safety standards based largely on the American National Standard for the Safe Use of Lasers in Health Care Facilities. The revised standards require laser centers to create safety programs and educate and train staff on the safe use of laser equipment. Outpatient sites must also provide appropriate laser fire protection - including portable extinguishers rated for electrical fires, water for dousing, "laser-safe" equipment and non-combustible materials and solutions.
  • Unlabeled-medication oversight. AAAHC now requires staffers to label all injectable or oral medications removed from their original packaging unless the medications are administered immediately, according to Dr. Philip. Her committee wanted to ensure consistent labeling of these medications, she says, because surveyors have pinpointed this as a problem area. The AAAHC doesn't specify on appropriate labeling of syringes, however. It's up to the organization to decide depending on its practice setting and kinds of medication used, according to Mr. Hochstadt.
  • Credentialing and privileging. Finally, the AAAHC clarified several credentialing standards. For example, the AAAHC now requires an acceptable secondary source verification for licensure and certain education and training, not just primary sources as written in the 2003 standard, says Mr. Hochstadt. AAAHC also put in writing the requirement that organizations must obtain National Practitioner Databank (NPDB) information when gathering information for the reappointment of practitioners - not just during the initial appointment. "We know that most organizations already do this, but again, we wanted to put it in writing," Mr. Hochstadt says. "It's good practice."

The latest hot spots
At this writing, the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) has not yet released its 2004 standards. However, the experience of the one-OR, two-physician Plastic Surgery Center of North Texas in Denton, which underwent its first AAAASF survey in June, may help you pinpoint key areas to address. Namely, advises Jana Thornton, RN, the center's nursing and clinical director, pay attention to the following areas to help guarantee survey success:

  • Documentation. While the AAAASF checklist "test" asks you to document required duties, like maintaining solid records, you will have to prove to the AAAASF inspector that you do what you say you do, says Ms. Thornton. For example, if you say you never administer medication to a patient without a physician order, make sure your records back this up. "It's not too hard to do this to ensure you are in good shape with record keeping," she says. "It's basic management." Since the Plastic Surgery Center of North Texas doesn't use computerized charts, Ms. Thornton periodically pulls a sampling of her paper records to ensure completeness.

    Ms. Thornton also checks the AAAASF checklist "test" periodically. For example, she says, the checklist helped her ensure that she was maintaining a thorough tissue log, which is clearly a focus area for plastic surgery facilities.

  • Disaster planning. Since the terrorist attacks of Sept. 11, all healthcare accreditors have paid close to attention to disaster planning. Be sure you have your own disaster plan and that it's in line with your community's disaster plan, says Ms. Thornton. Emergency preparedness is also important. Inspectors will question the availability of your emergency equipment, which includes everything from an emergency cart stocked with sufficient medications to maintaining fire safety equipment. For example, ask yourself whether your emergency power sources are in good working order, Ms. Thornton says. "Then they will look to make sure your policies and procedures reflect how prepared you are for an emergency," she adds.
  • Surgical-site marking. Wrong-site, patient and procedure surgery made headlines last year and, accordingly, most accreditors are taking a hard look at these issues. According to Ms. Thornton, her inspector wanted to ensure marking of patients before surgery and also checked to be sure the staff performed and clearly documented all sponge and needle counts. Says Ms. Thornton: Stringent documentation will set you free.
  • Technological awareness. Make sure your staffers read up on new technology, surgical techniques and available services that maintain modern standards of patient care, advises Ms. Thornton. "In the healthcare realm, things change quite often, so providers have to keep track," she says.

Ms. Thornton's final words of advice follow: Don't cut any corners, do what you're supposed to do and you won't have any problems. "The AAAASF gives you the list of standards, and it's just a matter of reading them and doing your homework," she says. Indeed, AAAASF surveys differ from JCAHO and AAAHC surveys in that inspections are an "open-book" test from the Standards and Checklist Booklet. Facilities must, however, demonstrate 100-percent compliance with the standards.