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What's Your Accreditation IQ?
Test your knowledge of these important accreditation requirements.
Dianne Taylor
Publish Date: October 10, 2007   |  Tags:   Accreditation

Regardless of your outpatient facility's setting, staying on top of changing accreditation requirements is a challenge. This quick quiz, split into hospital, ASC and office sections, will help you gauge your understanding of some of the more recent changes in accreditation standards. Answers follow each question.


1. The surgical team is ready to perform surgery on John Smith's right knee, a procedure that entails moderate sedation. The anesthesiologist has just performed the final airway assessment, the circulating nurse has marked the right knee and the surgeon signals his readiness to begin surgery. The surgeon asks the circulating nurse whether this patient is indeed John Smith, that they will perform knee arthroscopy, and on the right knee. The circulating room nurse nods her head and walks away to the instrument table. The surgeon nods to the team to start surgery. Given JCAHO's requirement to confirm the correct patient, procedure and site just before starting a surgical or invasive procedure, what did this surgical team fail to do?

A. The surgeon, circulating nurse and anesthesiologist failed to take a "time out" to confirm the correct patient, procedure and site.

B. The surgical team failed to indicate on a checklist the time of anesthesia administration.

C. The surgeon failed to check with the anesthesiologist to ensure documentation of the final airway assessment in the medical record.

D. The surgeon failed to confirm the correct knee with John Smith before anesthesia induction.

The correct answer is A.
According to JCAHO's first national patient safety goal - improving the accuracy of patient identification before any surgical or invasive procedure starts - the staff must conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site using active (not passive) communication. The time out must:

  • Take place just before surgery. It can precede or follow induction of anesthesia because the patient doesn't need to confirm the operative site.
  • Involve the entire surgical team. At a minimum, this includes the surgeon, anesthesia provider and circulating nurse. JCAHO encourages but does not mandate participation of other team members.
  • Involve active communication. This means that all members of the team must signal their agreement orally, with a nod of the head or another gesture. This doesn't mean everyone must repeat the same information; however, never interpret failure to respond as agreement.

One note: JCAHO's 2004 National Patient Safety Goals include three requirements directly related to wrong-site surgery (1b, 4a, and 4b). Until JCAHO's universal protocols to prevent wrong-site surgery take effect July 1, JCAHO will survey and score hospitals on these requirements.

2. Dr. Karnes is writing a discharge drug order for a patient and includes that the patient must take a sleeping pill at bedtime, listing the drug name and the abbreviation "HS" next to it. The patient's nurse prepares to discharge him and sees the drug and abbreviation in the medical record. She remembers seeing HS on JCAHO's suggested do-not-use list of abbreviations. She asks her nurse supervisor if Dr. Karnes wrote the order correctly and whether it should be clarified. The nurse supervisor responds that the abbreviation HS is acceptable since it is on the hospital's list of acceptable drug abbreviations, and that hospital policy states the facility need only prepare its own list. Did this hospital comply with JCAHO requirements by drafting its own list of acceptable abbreviations?

A. Yes. JCAHO states that hospitals must create a list of acceptable abbreviations, acronyms and symbols.

B. No. JCAHO requires hospitals to standardize abbreviations, acronyms and symbols and create a list of prohibited abbreviations.

The correct answer is B.
JCAHO requires organizations to identify acceptable and unacceptable abbreviations. Hospitals must share this information with all caregivers who handle drug orders. JCAHO created a minimum list, which became effective this year, of prohibited abbreviations, acronyms and symbols that must be included on hospitals' do-not-use lists (go to www.jcaho.org, then click on "Patient Safety Goals & FAQs" under "Top Spots.") HS isn't included in JCAHO's mandatory do-not-use list, but hospitals can add this or any potentially problematic term to their list of unacceptable abbreviations. As of April 1, JCAHO requires hospitals to identify and add at least three additional prohibited abbreviations to its mandatory do-not-use list. JCAHO's Web site offers suggestions for expanding the list with abbreviations such as HS. For the rest of 2004, JCAHO will score compliance only for handwritten, patient-specific documentation, including but not limited to orders. Starting in 2005, JCAHO will score compliance of all forms of clinical documentation, including electronic documents.

Ambulatory Surgery Centers

1. A patient visits your ASC for a simple ganglion cyst excision. The admitting nurse asks the patient for his name and compares it to the available paperwork, which consists of preprinted stickers for his medical record and pathology samples. The nurse feels this effort - that is, comparing the patient's verbal statement with the name on the preprinted stickers - meets the intent of JCAHO's first safety goal, which is to use two forms of identification to identify patients. In fact, many outpatients who present for a basic procedure or lab draw do not have an armband. Did the admitting nurse meet JCAHO's first patient safety goal?

A. Yes.

B. No. The nurse failed to ask for the patient's driver's license.

C. No. The nurse failed to ask the patient for a second identifier, other than the patient's name, to confirm his identity.

D. No. The nurse failed to place an armband on the patient.

The correct answer is C.
JCAHO recommends using two separate identifiers. In this scenario, the patient's name, although retrieved from two different sources, is just one identifier. Examples of a second identifier for a patient without an armband include date of birth, Social Security number, address or telephone number.

2. Jill Smith, the last patient to undergo a procedure at your ASC, needs to stay in the recovery area for at least one hour. The physician has completed his cases for the day and wants to leave, so he tells a non-ACLS-certified RN to stay on to ensure that Ms. Smith's recovery is normal and that her caregiver picks her up before the center closes. The physician makes sure the RN understands that the ASC has a transfer agreement with an area hospital, and says he'll be on call should anything abnormal arise. What should the physician have done to be in accordance with AAAHC's recently clarified requirement regarding the physician's role in post-op patient monitoring?

A. The physician should have stayed at the center until all patients were physically discharged.

B. The physician should have ensured that the nurse had his on-call number readily available before leaving the premises.

C. The physician should have ensured that an ACLS-certified employee remained on site to monitor the patient until medical discharge and that this employee had clear contact instructions for reaching him.

The correct answer is C.
AAAHC used to require a physician or dentist to be present or immediately available until medical discharge (patient release after clinical recovery from both surgery and anesthesia) of all patients. In the 2004 edition of the Accreditation Handbook for Ambulatory Health Care, AAAHC revised standards 9-K-1 and 10-I to require a caregiver qualified in advanced resuscitative techniques to be "present and immediately available" until medical discharge. The new standards also require at least one physician or dentist to be present or available by telephone while patients are in the center. In our scenario, the physician left a staff member, who may not have been ACLS-certified, in charge of monitoring the patient, but did the right thing by remaining on call for this patient.

Office-Based Surgical Suites

1. At your Class B AAAASF-accredited, office-based plastic surgery facility, patients often receive sedation with propofol-based total intravenous anesthesia (TIVA) but never undergo inhalational anesthesia. Historically, a CRNA has administered propofol but, on rare occasion, a trained RN has taken on this responsibility. Given AAAASF's new standard requiring all Class B facilities in which patients receive propofol to upgrade to Class C, the office's facility manager has issued this policy:

  • A CRNA or an anesthesiologist must be present when propofol is administered.
  • Neuromuscular blocking agents must be readily available.
  • Patient-monitoring equipment must be in proper working order.
  • The patient's circulation must be monitored via heart auscultation, intra-arterial pressure or ultrasound peripheral pulse monitors, pulse plethysmography or oximetry.
  • The patient's temperature must be monitored when clinically significant changes are expected or suspected.
  • A working oxygen source must be available.

Why does this policy fail to fulfill AAAASF's new standard regarding propofol administration in Class B facilities?

A. A dedicated CRNA or anesthesiologist must not only be present, but also must administer the propofol and monitor all life support systems during surgery.

B. The new AAAASF standard requires facilities administering propofol-based TIVA to ensure CO2 and ventilation monitoring and have a mechanical ventilator available.

C. The new AAAASF standard requires facilities administering propofol-based TIVA to ensure CO2 and ventilation monitoring and have a mechanical ventilator available, as well as use of an anesthesia machine and a protocol for treating malignant hyperthermia.

D. All of the above.

The correct answer is A.
AAAASF now requires facilities in which patients receive propofol as part of a TIVA regimen to ensure that a CRNA or anesthesiologist both administers the propofol and monitors all life support systems during the procedure. This person cannot function in any other capacity. All other requirements outlined in this facility manager's policy are correct and required by AAAASF.

Importantly, the new standard also requires facilities in which patients receive propofol as part of a general anesthesia regimen, including CO2 and ventilation monitoring and availability of a mechanical ventilator. Finally, when a patient receives inhalational anesthesia (volatile agents such as desflurane or sevoflurane; nitrous oxide) - regardless of how often other patients in the facility might receive a propofol sedation reg- - the facility mustmachine, a imen - the facility must also have an anesthesia machine, a protocol to treat malignant hyperthermia, and certain other safeguards in place. For more information, go to www.aaaasf.org/Standards.

2. A physician-owner and quality manager at an AAAHC-accredited, office-based surgical suite are working on a quality improvement study using the AAAHC "closing the quality improvement (QI) loop" process. They suspect they have too many non-narcotic (antibiotic, antiemetic and blood pressure) medications on hand and are performing a cost study to determine if their pharmaceutical inventory is overstocked. The physician and manager decide to compare current inventory of their non-narcotics with the monthly utilization of these medications and report their findings to the quality committee. They file a one-page report into a reference binder and agree to undergo the same assessment again next year. Why does this exercise fail to satisfy the AAAHC requirement for performing QI studies (standard 5IIC)?

A. The physician and quality manager failed to include other staff members in the study.

B. The physician and quality manager did not evaluate measures to resolve the concern, nor did they subsequently re-evaluate the problem to ensure resolution.

C. The physician and quality manager did not report any actions taken to the governing body.

D. The study topic is not clinically relevant and thereby does not qualify as a QI activity.

The correct answer is B.
The physician and manager omitted steps three and four of AAAHC's 5IIC standard; the five steps for closing the QI loop are:

1. Identify an important problem/concern.

2. Evaluate the frequency, severity and source of the suspected problem/concern.

3. Figure and implement measures to resolve the problem/concern.

4. Re-evaluate the problem/concern to determine if corrective measures have achieved the desired results.

5. Report activities to the governing body.

In our scenario, the manager and physician could have more accurately evaluated the frequency, severity and source of the problem by reviewing inventories over a six-month period and determining total stock utilization, average cost per case and current stock. Importantly, the re-evaluation should not simply mimic the original study; it should demonstrate that your corrective measures were (or were not) beneficial. In our scenario, for example, the physician and manager could have re-evaluated by assessing actual cost savings and gauging nursing and anesthesia satisfaction with the accessibility and availability of medications.

Unfortunately, some healthcare professionals tend to create overly complex QI studies and, as a result, collect and analyze unnecessary data while failing to accurately identify the problem. To avoid the dreaded perpetual QI study, focus on one issue and keep the study simple.

3. Joanne Key, the receptionist at a five-physician cosmetic surgery center, has some rare downtime to make follow-up phone calls to patients who underwent surgery during the past few days. The center policy states that while it's a good idea to contact patients, staff members aren't required to contact every patient. Just as Ms. Key is about to make the calls, the phone rings, and she finds herself busy for the rest of the day. Because Ms. Key didn't make any follow-up phone calls, did she violate JCAHO or AAAHC standards?

A. Yes. Both AAAHC and JCAHO standards require follow-up phone calls.

B. No. Neither AAAHC nor JCAHO specifically require follow-up phone calls.

The correct answer is B.
Neither AAAHC nor JCAHO require follow-up phone calls.

JCAHO lets facilities define a meaningful system for obtaining patient feedback and lets facilities base the follow-up timeframe on patient needs and the type of treatment. Clearly, follow-up phone calls are an effective way to obtain feedback.

AAAHC requires facilities to develop procedures for observing and caring for patients during post-op recovery, and AAAHC requires protocols for instructing patients in self-care after surgery. These protocols can include written instructions specific to the type of anesthesia care and/or procedure.

4. The manager of an AAAASF-accredited office-based facility tells the physician-owner the facility doesn't fully comply with three AAAASF drug-inventory standards. The physician tells her to set up a proper system for verifying drug inventory and to obtain the required amount of amiodarone. He tells her not to worry about purchasing a stationary drug inventory case, because the matter is relatively minor, the substances are already double-locked and the facility complies with all other AAAASF standards. Is this decision acceptable?

A. Yes. AAAASF would likely view this small lapse as an exception and continue to fully accredit this facility.

B. No. Although AAAASF says its inspectors are flexible and will let facilities correct deficiencies provided they don't compromise safety, it requires all facilities to achieve 100-percent compliance with every standard.

The correct answer is B.
AAAASF requires 100-percent compliance with each and every standard. There are no exceptions. AAAASF says it allows for "reasonable flexibility and room for individual consideration" as long as "patient and staff safety remain uncompromised."