Once you've spent the time and resources to achieve accreditation, "Why let all that knowledge go to waste?" asks Annamarie Carey-York, MBA, the executive director of Kendall Pointe Surgery Center in Aurora, Ill.

If you view accreditation as a one-and-done (whew!) nuisance, you're missing the opportunity to run your facility in a high-quality mode as a matter of routine. The advent of the unannounced survey could have something do with it, but the managers we reached out to say the concept of being survey-ready 365 days a year is slowly catching on as surgical centers shift their focus from feverishly preparing for a survey to continuously improving their operational systems. The administrators and accreditation experts we talked to say being in a state of constant readiness isn't nearly as hard as it sounds.

1 Reframe the relevance of accreditation.
Articulate that accreditation is not an exercise in futility but a framework by which your facility is organized, says Ms. Carey-York. "Your staff must see the correlation between standards and the facility's policies and believe in the relevance to their everyday tasks," she says. "Clearly understanding the ?standard-policy-relevance to my job' relationship fosters ownership and creates value to their role in the facility."

2 Conduct mock surveys.
What better way to see how your facility will fare in a survey than to actually conduct one yourself? "You learn a lot from a mock survey," says plastic surgeon James A. Yates, MD, the president of AAAASF.

"You get a chance to find out where you're weak," says Ms. Carey-York, who suggests doing quarterly mock surveys. Focus on the key accreditation areas: credentialing, policies and quality improvement. Hint: Follow the standards your accreditation body provides you.

"The accreditation bodies provide standards to guide you and your staff in providing a high standard of care. By implementing these standards into facility policies, procedures and normal business operations, your facility can conduct its business in a high-quality mode as a matter of routine," she says.

Do the surveys during peak periods, not on slow days such as Fridays, says Michael Kulczycki, JCAHO's executive director. And use the business staff, because they may be able to see what others don't normally see, he adds.

For example, use your billing clerk or the business office manager to conduct a patient tracer through the clinical area. "They may approach the scenario with fresh eyes and identify areas of non- or partial compliance differently than a clinician who works in that area daily," says Mr. Kulczycki. Alternatively, use a clinician to conduct a patient tracer through the registration and billing steps in order to determine compliance with standards in such areas as proper patient identification, patient privacy and HIPAA protection, he says.

"The biggest thing is staff education," says Barbara Ramsey, RN, the administrator of Rush SurgiCenter Ltd. Partnership in Chicago. "It used to be that [accreditors] would go with the management team to talk about the policies and procedures, but now they talk to the actual people who are taking care of the patients." That's been more the case since JCAHO implemented tracer methodology in its surveys in 2004. She also thinks in-service meetings are great educational opportunities for employees.

3 Review policies and procedures.
Here are some strategies for keeping up with the policies year-round.

• Schedule the time to review your policies and procedures for relevance and accuracy, says Ms. Carey-York. Annually read and interpret changes or additions to the standards of your accreditation body and update your policies to comply, she says. If, as you're reading over your policies and procedures, you realize that employees are straying from the path, find out why, says Ms. Carey-York. "Perhaps you need to change the policy or retrain the employees," she says.
• Check your accreditation body's Web site for any changes to their standards on a weekly basis. AAAASF, for example, implemented Web-based accreditation last April so that ASCs can prep for their accreditation surveys any time of the year.
• Reinforce the standards and foster personal ownership among the line employees, says Ms. Carey-York. "Ideally, each employee should hold herself accountable to do the right thing," she says. To reinforce the standards, you must have a thorough knowledge of the standards, state and federal laws, and any changes. "There is nothing more deflating than an administrator who uses the phrase ?it's a so-and-so standard' incorrectly. To encourage your staff members to be prepared, you must be technically proficient in the standards, be able to interpret and apply them to your organization, and practice them day in and day out," she says.
• Set up your facility's policies and procedures manual to follow the same format as the accrediting body your center is a member of, says Ken Summerhays, RN, the director of nursing at AAAHC-certified Coral Desert Surgery Center in St. George, Utah. "That makes it so easy and so smooth - like the surveyors are looking at their own manual," says Mr. Summerhays.
• Establish a checklist from your standards and hit the checklist once a quarter, says Sandra Jones, MBA, CASC, an AAAHC surveyor and principal of Woodrum/Ambulatory Systems Development in Dade City, Fla. Keep all the guidelines together in one place, such as a red binder, suggests Mr. Kulczycki, so they'll be ready to hand over to the surveyor whenever he pops in.

4 Form QI committees.
Karen Bennett, RN, administrator of the Academy Orthopedics Ambulatory Surgery Center in Cumming, Ga., uses an Internet program to track trends and benchmark against other similarly-sized (one OR) facilities. She and her team discuss the results in quarterly quality improvement committee meetings and also report to the board of directors.

Mr. Summerhays recommends reviewing one accreditation topic in each monthly staff meeting. Not only will accreditation standards become familiar to staff members at all levels, but also suggestions about solving procedural problems can come from staff.

Trying to play catch-up in the area of QI is nearly impossible, says Ms. Carey-York. "QI is ongoing because every organization must accept that change and process improvement is inevitable and good," she says. "Dig out your written QI program and dust it off. Identify opportunities for improvement: turnover time, infection rates, unplanned hospital transfers or admissions, return to the OR, complications in the OR or PACU, case cancellations and patient satisfaction." A hint: Make sure you note your QI report, recommendations and actions in the minutes of your governing body. "Your accreditation organization will be examining those minutes to confirm that you practice what your written program preaches," says Ms. Carey-York.

5 Keep current on credentialing.
Credentialing of staff and physicians is a hot topic, says Jaime Trevino, AAAASF's communications director. Keep current information about licenses, board certification and up-to-date hospital privileges. In today's software programs, you can set up automatic reminders for when a license expires. "The value of automatic reminders for pending expiration dates far outweighs the initial hassle of data entry," says Ms. Carey-York. "Work with the physicians' offices to encourage their staff to automatically notify you of any changes. Educate your staff on how to verify the privileges granted to physicians. Periodically review the privileges granted and the actual procedures the doctor is performing." The issue extends to nurses now that they're authorized to administer sedation.

When JCAHO stripped Flagstaff Medical Center of its accreditation last December, the accrediting body cited credentialing as one area among several that required improvement, says JCAHO spokesman Mark Forstneger. The JCAHO surveyors noted that the surgical facility should review the credentialing process for its organized medical staff, examine the process for granting, renewing or revising setting-specific clinical privileges, and take another look at how they evaluate individuals at the time of privilege renewal.

JCAHO also cited Flagstaff, which had been accredited since 2000, for major issues involving medical staff, medication management, management of information, environment of care, provision of care, treatment and services, among other problems, according to Mr. Forstneger. Though the Flagstaff Medical Center chose to accept JCAHO's denial of accreditation, a hospital spokesperson said Flagstaff would pursue accreditation with CMS.

For more information on credentialing, see "Better Ways to Credential Your Surgeons," November 2005, page 28.

6 Integrate peer review into QI.
Incorporate peer review into your business operations throughout the year or you won't be prepared for your next round of surveys, says Ms. Carey-York. But know why you're doing it: Many facilities that perform peer review because it's an accreditation requirement are unsure of its intended purpose, she says.

Reasons for peer review can include quality of care assurance, determining medical necessity, review of adverse events or simply periodic review of a physician's charting, she says. Determine what criteria will launch peer review for your organization. Any of the following can be flagged for quarterly peer review: hospital transfer or unexpected admission, complication in the OR, extended stay in PACU, patient complaint or reported infections. You could also randomly audit charts from the busiest physicians or any new physician just starting to practice at your facility. Re-credentialing of facility physicians should automatically trigger peer review.

7 Think patient safety.
Let's not forget the chief goal of being accreditation-ready 24/7: patient safety.

"The big hot button issue is patient safety," says Deb Sterkenberg, MS, RN, the clinical nurse manager for the Surgery Center at Limerick in Pennsylvania, "from registration to discharge to reuniting with the family."

One way that Ms. Bennett addresses the issue is a diagnostics summary filled out for every patient's visit. A AAAHC surveyor recommended it when he came to evaluate her facility and the idea has been "very helpful" in maintaining patient safety standards, she says.

For Ms. Ramsey, adhering to patient safety goals includes testing the heart rate and blood pressure monitors at least once a month and taking steps to prevent wrong-site surgery.

A constant vigil
"Every impending survey launches some heightened form of anxiety for administrators and their staff," says Ms. Carey-York. "Many facilities have grown tired of the disruptive atmosphere an impending survey brings forth."

But it doesn't have to be that way. As our sources have described, your facility can remain on constant vigil in adhering to the guidelines dictated by accreditation agencies. As David Shapiro, MD, a AAAHC surveyor, anesthesiologist and corporate medical director for Surgis Medical Center in Nashville, Tenn., puts it, "I like to learn from every site. I consider it a successful survey if I'm able to learn something and improve patient care."

Being prepared for a surveyor 365 days a year should almost be automatic. "We don't need to be ready for anything. We should already be doing what we're supposed to be doing," stresses Ms. Sterkenberg. "When an accrediting body comes through, it should be no different than any other day that you're operating."