So Much More Than the Survey

Credentialing

By: Danielle Bouchat-Friedman

Published: 12/6/2022

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Accredited facilities demonstrate a year-round commitment to safe surgery, ongoing quality improvement and excellent patient care.


Accreditation is more than a simple stamp of approval. Sure, accredited facilities meet nationally recognized quality measures, implement evidence-based clinical practices and adhere to rigorous standards of safe patient care, but the true benefits stem from the process itself. Copper Ridge Surgery Center in Traverse City, Mich., has been accredited since opening its doors in 2004 and must seek reaccreditation every three years. "Going through the process is absolutely a tool for continuous process improvement," says Tina Piotrowski, MBA, BSN, RN, CASC, the facility's CEO. "It enables you to constantly assess your practices to see if they meet the standards. You then have an opportunity to improve areas where you fall short."

Ms. Piotrowski says it's important to immediately fix the deficits a surveyor observes. "Remedy them as soon as possible," she explains. "During your next reaccreditation survey, the surveyor will look back at the previous survey's notes and zero in on the opportunities for improvement to make sure they were taken care of."

Ms. Piotrowski says her staff will typically start to prepare for reaccreditation about a year in advance. "Shortly after a survey is completed, you receive your findings and the decision letter," she says. "In addition, you receive a timeline for preparing for reaccreditation."

Review the latest standards and monitor new or revised directives in order to remain in compliance, recommends Ms. Piotrowski. "Try to be survey-ready all the time," she says. "That way, you can constantly determine if your center needs to conduct a mock survey, which is a helpful exercise, especially if you've implemented new protocols or added new staff members who haven't been through the survey process."

Preparing for a surveyor's visit is not a job for procrastinators or a responsibility one staff member can handle. "Designate a point person to lead an accreditation committee," says Ms. Piotrowski. "Pull a leadership team together that meets every few weeks and determine who's going to take ownership in making sure the staff and facility comply with the standards noted in each chapter of the accreditor's manual." Ms. Piotrowski notes that her facility's committee is not made up of only managers and supervisors — team members from different departments participate in the meetings. "It's important to involve frontline staff, so they can help revise policies and procedures," she says.

LOOKING AHEAD
How Will COVID-19 Impact the Survey Process?
REMOTE ACCESS Some accreditation organizations might switch to hybrid or virtual survey models as the pandemic continues.

Four organizations offer accreditation for ambulatory surgery facilities: The Joint Commission, American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (AAAHC) and Healthcare Facilities Accreditation Program (HFAP). Each organization shared how the pandemic effected the survey process and how they're handling surveys moving forward.

  • The Joint Commission. CMS has provided The Joint Commission with approval for conducting surveys during the public health emergency using a virtual platform, with the expectation that on-site surveys will resume as soon as it is safe to do so. The organization plans to continue with the current survey process and incorporate the virtual process as appropriate to ensure everyone's safety in areas where COVID-19 rates are high and travel is restricted. In addition, the use of virtual technology and alternate observation processes during on-site visits to limit exposure will likely continue through 2021.
  • AAAASF. Due to travel restrictions as a result of the global COVID-19 pandemic, AAAASF developed the virtual survey process for facilities seeking start-up surveys. The first virtual survey was conducted for a new office-based surgery facility in Oregon. The virtual survey allowed for expedient scheduling and posed no barriers for the surveyor to assess compliance with standards. New York Department of Health approved AAAASF to conduct start-up surveys for new office-based surgery facilities from June through Oct. 31, 2020. As survey activity resumes, AAAASF wants to establish the facility is open and providing patient care and if there are any state regulations or travel restrictions that would impact its surveyors. The facility must also provide information about instructions and precautions for entry into their building and the provision of PPE.
  • AAAHC. As the COVID-19 pandemic situation continues to evolve, AAAHC has no plans to change the onsite survey format in 2021. Program participants have expressed that they value the face-to-face interaction and expertise delivered through the onsite survey. However, the organization is exploring virtual or hybrid survey models as a complement to the onsite survey. Additionally, AAAHC is committed to keeping clients apprised of changes to the current guidance related to the pandemic and impacts on accreditation. As AAAHC continues surveying organizations, continuous readiness becomes ever more important. Some organizations may have been unable to comply with all requirements depending on their situation during COVID-19. Readiness checklists offered by AAAHC provide guidance on specific COVID-19 pandemic considerations regarding resuming onsite patient care and compliance with the organization's standards.
  • HFAP. When onsite survey activity was paused for several months, HFAP began collecting data from facilities waiting to be surveyed with regard to the impact COVID-19 has had on their organization and conditions in their community. HFAP continues to collect this information and make scheduling decisions based on conditions on the ground and availability of surveyors. While HFAP is interested in looking at aspects of accreditation that might be effectively handled virtually, the organization believes nothing can replace the experience of having a survey team on-site to observe actual practice and provide educational insights that lead to quality improvement.

— Danielle Bouchat-Friedman

After each chapter of the accreditation manual is assessed and addressed, have staff participate in a crosswalk, or a side-by-side comparison of accreditation policies and how your facility meets them. Document the title of the policy and how you meet each policy's specific standards, suggests Ms. Piotrowski. This exercise lets you track which standards your facility meets — and which it doesn't.

This is when having extra time to prepare for a survey truly comes in handy. Ms. Piotrowski says her team sometimes realizes they have more work to do than they first thought to make sure the facility complies with the accreditation standards. "It's important to schedule enough lead time to update policies and procedures and get the revisions approved by the facility's governing body," says Ms. Piotrowski.

Try to be survey-ready all the time.
— Tina Piotrowski, MBA, BSN, RN, CASC

Centers that don't have a lot of experience with the accreditation process should consider having an outside consultant conduct a mock survey, suggests Ms. Piotrowski. This is a non-threatening way to have an experienced professional assess practices and processes through the eyes of a surveyor. "It's also very helpful to have someone from another department, say from the business office, play the role of the surveyor," she says. "They might look at things from a different angle and fresh perspective."

Patient confidence

PRACTICE RUN Staff members can serve as mock surveyors to give your team the insights into what they need to know and how they need to prepare for the real test.

More patients are choosing to have surgery in outpatient settings, and those numbers are expected to keep increasing due to the persistence of COVID-19. Achieving accreditation has helped Copper Ridge adjust to the new standards of care. "There are many additional layers of infection prevention that have to be put in place during COVID-19," says Ms. Piotrowski. "Having a solid foundation for meeting accreditation requirements has really helped during this time."

One of the best compliments her team ever received came from an accreditation surveyor, who said they wouldn't hesitate to send family members to the facility for surgery, and that they would also feel comfortable having a procedure performed in its ORs.

"After they've examined our processes and followed the patient throughout their experience, surveyors get to observe what type of care our team is delivering," says Ms. Piotrowski. "And for them to say they feel personally very comfortable in the quality of care we provide was a great endorsement to receive." OSM

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