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Top 14 Accreditation Slip-ups
These are the mistakes surveyors see most often, the easy-to-fix lapses you won't make if you read this article.
Dan O'Connor
Publish Date: August 7, 2008   |  Tags:   Accreditation

Whether you're sweating your next survey or wondering why you didn't do as well as you thought you would on your last one, here's a list of common errors three longtime accreditation surveyors say you should avoid.

1. Don't post your notice of accreditation visit. That's the first thing Karen McKellar looks for when she walks into a facility to conduct an accreditation survey. "It's supposed to be right there in public view," says Ms. McKellar, senior administrator for the Lake Chelan Clinic in Chelan, Wash., and a surveyor for 15 years. "It's almost always there, but you'd be surprised how often such a simple thing is overlooked." She also takes the waiting room in, getting a general overall impression. "Is it neat, clean and welcoming?" she asks.

2. Don't prominently post patient rights and responsibilities in the waiting room. Some organizations fail to delineate patient responsibilities along with patient rights, while others fail to inform patients of mechanisms for expressing grievances. One thing more about your waiting room: Be sure you have a place where patients can discuss private and confidential information while they're standing at the registration desk. "When we notice this taking place at a survey, we recommend some way — perhaps a room divider or going to an area other than the waiting room — to discuss the confidential and personal information," says Jack Egnatinsky, MD, a retired anesthesiologist and longtime surveyor.

3. Don't prepare or involve your staff members. It's not enough that you're familiar with standards — your staff must be as well, says Paula Russo, RN, of St. Petersburg, Fla., who helps surgical facilities prepare for accreditation. "Surveyors want to speak to staff and staff needs to know," says Ms. Russo, who offers these tips to get staff involved in the accreditation process: Have regular staff meetings to review standards; purchase manuals offered by accrediting agencies and review them chapter-by-chapter with physicians, staff and anesthesia; and send key staff to accreditation conferences.

4. Don't modify the policies and procedures manual you borrowed. It's OK to use policies originally created by consultants or other surgical centers, but it's not OK to not modify them to fit your individual needs, says Ms. Russo. Dr. Egnatinsky raises a red flag when he sees a procedures manual on your bookshelf with another center's name on the binder, or if it references a stairwell and you don't even have one. "At least change the name and modify it to fit your needs," he says. "If you haven't even bothered to do that, I get concerned. It says to me that you're not even familiar with your own policies and procedures. So I'll look in greater depth to see if you're aware of what you say you should be doing." Ms. Russo adds that other facilities can be great resources if you're missing a certain policy.

5. Don't verify that the physician received a copy of the pathology report. "Each surveyor has items that are important to her — I call them ???hot buttons,'" says Ms. McKellar. One of her hot buttons: having a system of checks and balances on laboratory send-out tests. She calls it "closing the loop." When you send tissue to a pathologist, Ms. McKellar will check to see that the specimen was labeled, that a note in the medical record indicates that it was sent, that there's a log that shows that the tissue sample was picked up, that the report came back, that the surgeon reviewed and signed off on the report and that it was filed appropriately. Why is this a hot-button item? "From a patient care and risk management standpoint, you can't afford to miss test results," says Ms. McKellar. "Don't rely on the pathologist or the lab to get a copy of the report to the physician. Make sure that you close the loop."

6. Don't buy the most recent standards book. Whichever accrediting organization you go with, by all means buy its most recent standards book. Then, of course, "make sure you know what all the standards are and that you're meeting them," says Ms. McKellar. Ideally, adhering to all standards that apply to you should be a daily ritual, not a three-month cram, she says. "Here's a standard. Do you teach your people about it? Do you make sure that it's happening?" says Ms. McKellar.

7. Don't benchmark. AAAHC used to suggest that you benchmark. Now it requires that you compare yourself to other like facilities or published standards. Joint Commission standards require hospitals to use benchmarking tools when evaluating programs and services and expect ASCs to do so. AAAASF doesn't require benchmarking, but does have a mandatory peer review reporting system.

"Most facilities that have a problem with [benchmarking] don't know how to go about it," says Ms. McKellar. Use published resources, data from your corporate partner, national associations (AORN or ASCA) or commercial outfits (Surgical Outcomes Information Exchange) that provide such data. "The thing we want to see is that you're comparing yourself to like facilities," says Ms. McKellar. "And if there's room for improvement, that you make it and sustain it." On a practical level, benchmarking is a mechanism to make sure that your facility is paying attention to delivering quality health care, says Dr. Egnatinsky. "If you never bother to look at benchmarking for PONV — what percentage of patients have that problem and what percentage have that problem under certain meds — patients may not be receiving the best care possible," he says.

A common mistake is to do external benchmarking, but then fail to create an internal benchmarking study based on the data collected. "After you've participated in a benchmarking study and you see where you stand, then you want to compare yourself six months or a year later," says Dr. Egnatinsky. "Benchmark against yourself to see if you've improved. Compare yourself to yourself: You can go from pretty good to very good."

8. Don't document QI studies. A quality study should have purpose and meaning, says Ms. Russo. "Why is there a problem, why is it being studied and what is the plan for resolution?" she says. Accreditation manuals provide study measures. Although the two are related, don't confuse quality monitoring with quality improvement studies, says Dr. Egnatinsky. For example, he says QM is what you'd call reviewing a certain number of charts to make sure they're all complete and finding that lab reports and path reports are not initialed or signed by the responsible practitioner. "You'd then do an in-depth [QI] study to find out why that's not being done and what you can do to be sure it does get done," says Dr. Egnatinsky.

9. Don't perform peer review the right way. Because many facilities don't understand the definition of "peer," they end up performing simple chart audits instead of actual peer reviews, say our experts. "The common mistake we see is a facility will have the medical records reviewed by one of the nursing or clerical staff rather than having the physician's peer — someone with the training and education who can make that professional judgement — review the physician's documentation," says Ms. McKellar. "What we want is a physician to look at the surgeon's and anesthesiologist's documentation of the process and of the procedure. Was there an adequate history and physical? Was the working diagnosis consistent with the findings? Was there adequate documentation?" Single-surgeon facilities should enlist another physician for peer review, says Dr. Egnatinsky.

Peer review should include outcomes monitoring, says Dr. Egnatinsky. There should be documentation in the credentials files or governing body minutes that the results of peer review have been used to determine continuation of clinical privileges, he says.

There are two types of peer review: proactive and reactive. Surveyors want to see both. Proactive means randomly pulling some number of records for surgeons and anesthesia providers and having a peer review the charts and ask the tough questions. In reactive peer review, a single incident or a specific set of outcomes is explored. For example, let's say the physician's office reports a post-op infection to the surgical center. "You'd pull that chart and a peer would review it to see if anything in the process could have led to a potential problem," says Ms. McKellar.

10. Don't do primary source verification in credentialing. "It's up to you to know if your medical staff or allied health personnel have actions against their license," says Ms. Russo. It's not acceptable to use a photocopy to verify licensure and education information provided to you. And when you do verify information, use a primary source (hint: the National Practitioner Data Bank is a secondary source) such as the American Medical Association, the Office of Inspector General, the Drug Enforcement Agency, the Department of Business and Professional Regulation or the state licensing department, say our experts. Secure credentialing files so that they pass the "shake test" — if a file is turned upside down, it will remain intact, says Ms. Russo.

11. Don't take board minutes. You'll get dinged if your board meeting minutes don't accurately reflect what's happening in your facility or activities aren't shared with the board. "Minutes should reflect that you reviewed quality and benchmarking activities," says Ms. Russo.

12. Don't review a random sample of your medical records before survey. The surveyor will ask for a sample of your medical records that will include transfers to a higher level of care, admissions to the hospital, wrong site/sided procedures and death, says Ms. Russo, who shares these tips:

  • If you have an EMR system, make someone available to navigate the system with the surveyor.
  • Be sure a physician has acknowledged lab, X-ray and ECG results on the charts.
  • For patient hospital admissions, have a discharge summary from the receiving facility.
  • Patients with multiple visits should have a summary sheet updated for each visit.
  • Note allergies in a prominent and consistent fashion, keeping in mind that the more locations you have allergies noted, the higher chance of transcription errors.

13. Don't document required drills. Internal (may include fire, malignant hyperthermia occurrence, or infant, child, adult cardiopulmonary arrest) and external (hurricanes, floods or earthquakes) drills may be required for accreditation, says Ms. Russo. One of the internal drills needs to include CPR, but don't mistake a CPR class for this standard. Since fire drills are required for staff, check to see if your local fire department may be able to assist. And be sure to document on your fire extinguisher's tag each month that it's fully charged, reminds Ms. McKellar.

14. Don't worry about personnel records. Accrediting organizations have manuals for purchase that can assist with these standards, says Ms. Russo. Keep in mind:

  • An I-9 (Employment Eligibility Verification) must be on file.
  • Document that you verified references before you make an employee an offer.
  • Keep a (signed) job description on file; a surveyor could assume an unsigned description was never reviewed.
  • Hepatitis B testing should be offered to or refused by an employee within 10 days of hire and TB testing results should be present.
  • The "shake test," as previously mentioned, applies here, too.