As you may know, keeping physicians interested in the accreditation process is no easy task - especially if they aren't owners. Not only does accreditation require surgeons to find time to engage in peer review, sit on committees and review medical record after medical record, but doctors with entrepreneurial spirits can feel put upon when they perceive an accrediting agency telling them how to practice. Still, the only way to achieve the main goal of accreditation - patient safety and quality care - is for those who actually provide the care to be actively involved in the process. To help facility managers find ways to engage physicians, Outpatient Surgery polled readers who've already met the challenge. Here are the highlights from our 96 respondents.

1. Manage Perceptions
Many facility managers stressed the importance of managing physicians' perceptions. Whenever possible, they say, avoid the word "accreditation" and instead present projects in the context of the rationale for doing them in the first place. "If you have the patient at the heart of what you are trying to accomplish, you will develop a culture that puts the patient first, and everything else will outflow from that," says Mary Diggles, a CRNA with On-site Anesthesia Services, Inc., a West Linn, Ore.-based anesthesia group that offers services to ASCs and physicians' offices.

Shirley E. Zemansky, RN, MBA, MSEd, the executive director of the Hinsdale Surgical Center, LLC, in Hinsdale, Ill., puts it more bluntly: "Nothing turns doctors off faster than saying 'We're doing this because JCAHO requires it'," she says. "So, we try to place emphasis on 'We are doing this because it is the right thing to do to assure quality patient care'' No one wants infections, pain, poor outcomes or dissatisfied patients, and physicians will buy into any activity that has to do with this." Thanks to this approach, she adds, physicians at her facility "participate without even realizing they're participating."

2. Demonstrate What's In It For Them
Reluctant physicians may realize the need for accreditation when they can see how it benefits them, say our responders. Here are some of the biggest benefits they cited:

• Improved patient care. In Ms. Zemansky's facility, a recent pain management program shows how accreditation requirements can improve patient care. Ms. Zemansky and her team undertook an extensive assessment of post-op pain using pain scores and follow-up telephone calls to meet a JCAHO performance improvement requirement. After pinpointing problem areas, she and her team shared the results with the physicians, who were more than willing to address the issues. "As a result, our doctors now use long-acting regional blocks for shoulder surgery patients, and this has made a big difference," says Ms. Zemansky.
• Improved efficiency. Several responders noted that benchmarking efficiency and cost-containment efforts against national averages - and even comparing costs per case among physicians within the facility - evokes physicians' competitive nature while meeting accreditation requirements. Rita Roberts, RN, an administrator for the Long Island Surgery Center in Garden City, N.Y., points to her recent turnover study as one example of how accreditation improved efficiency in her facility. "We had a problem with turnover time in the recovery room, and we undertook a quality improvement project to meet our accreditation requirement," says Ms. Roberts. "We found that nurse anesthetists and anesthesia providers had different methods, and we determined which providers were scoring patients in the endoscopy room." These findings, she says, helped the staff develop a "rapid recovery policy" that has since hastened turnover time.

At the Healthsouth Endoscopy Center West in Cincinnati, Ohio, Director of Nursing/Administrator Linda Ballhaus says her JCAHO-mandated performance improvement projects have helped reduce recovery and turnover times. Her staff was alarmed at the results of a time study: They were losing an average of 14 minutes per case because they let patients' families stay in the recovery area. "This delayed physicians between cases and inhibited our ability to monitor patients and move them through the process," says Ms. Ballhaus Now, she says, they maintain stricter controls over family visitations.

• Litigation protection. Several readers stressed the significance of accreditation as a tool for preventing and fighting litigation. "I've explained to [physicians] that our professional liability insurance carrier requires that we become accredited and that their involvement is imperative," says Kecia Weimer, the manager and administrator of the Ambulatory Surgery Center of Burley (Idaho). "They understand the importance around liability insurance issues."

Accreditation in and of itself can also help prevent untoward events in the first place, according to the Long Island Surgery Center's Ms. Roberts, who in a prior position was involved in a serious sentinel event in the outpatient setting. "And if something does happen, everyone will know right away if you're Joint Commission-accredited ' Physicians involved in an event come to understand that accreditation is worth its weight in gold."

• CME credit. At the rural Montgomery General Hospital in Montgomery, W.Va., Director of Anesthesia and Surgery Lou Ann Bowen, CRNA, interested her physicians in accreditation when she added a JCAHO standards review to the hospital's CME agenda. "We dissected the JCAHO manual and dedicated one CME class a month to this topic, thereby spreading it out over a year," says Ms. Bowen. For example, she says she performed a critique of existing patient charts at the meeting dedicated to charting. "We included our nurses and did not focus only on what the physicians did wrong ' It was a great way to encourage teamwork and prepare for our survey," says Ms. Bowen.

3. Make The Most Of Their Time
Many poll respondents emphasize the importance of making the most out of physicians' time, and they offer several ways to accomplish this objective:

• Manage their schedules. "The key to keeping physicians motivated to attend medical staff meetings is to be very organized and concise when presenting information and utilize their time efficiently. If physicians feel the meeting is a waste of time or that nothing important is accomplished, they are not going to be very motivated to attend," notes Lori Sterbenk, RN, the director of nursing for Healthsouth's Physician's Plaza Surgery Center in Bakersfield, Calif. "For example, work around the physician's schedule to set meeting dates and times, provide them with dinner, start and end the meeting on time, be organized and know what you need to accomplish."
• Do the legwork. Many respondents say they present information to physicians only after they interpret, synthesize and summarize it. "I recommend having the staff do the legwork," advises Darlene Johnson, administrator with the Surgery Center of Cleveland in Cleveland, Tenn. "Whatever the topic, whether it is peer review or quality improvement or something else, do the homework for them so they can make informed decisions ' Draft the findings and allow them to edit, [then] allow them to do the presenting at board meetings with the written results in hand. ' Time is a huge issue for all physicians." For example, she says, have the staff audit patient charts before the physician audit to reduce their time spent poring over normal findings.

Ms. Ballhaus with the Healthsouth Endoscopy Center West assists her physicians when undergoing accreditation surveys by making out "cheat sheets" that succinctly review what the staff has done to meet key standards. "This sheet lists the main things we think surveyors will question us about, as well as newer policies and procedures (like HIPAA). It also includes an environment of care handout (safety, security, hazmat, emergency preparedness, life safety management, equipment management and utility management)," says Ms. Ballhaus. "We must keep putting things in front of them ' that are short and to the point."

• Post important notes above scrub sinks. Several respondents said they post their concise, bulleted lists of important accreditation information above the scrub sinks so the physicians read it while they prepare for surgery. "When we implement something new, we communicate with surgeons in writing over the scrub sinks," notes Ms. Zemansky. "We only do this when it's important. They know this, and so they read it."

4. Keep It Factual
Some recommend keeping communications purely factual, because this approach is most effective for the clinically and scientifically oriented mindset of most physicians. "Physicians like hard proof ' if they are asked to make a change," says Debra Eisner, administrator with Inland Surgery Center in Redlands, Calif. According to CRNA Mary Diggles, this approach also helps remove emotions and prevent power struggles that can hinder progress.

"The most reasonable way to approach this is not on an emotional level but on a patient safety level, and out of that flows core procedures that focus on the patient," says Ms. Diggles. "This lets you write policies that doctors can live with. I've found that doctors are much more responsive." Refrain, she says, from getting mired in personality issues by keeping the patient at the center of all communications.

5. Be Fair But Firm
Outpatient facility managers recommend approaching the process fairly, while always remaining firm. This means educating physicians, telling them exactly what you expect, and refraining from placing undue burdens on them. "Any change, no matter how small," must be preceded by consensus-building, says Todd E. Barnett, RN, MBA, the director of surgical services for the Southern Ohio Medical Center in Portsmouth, Ohio. Just "flipping the switch and expecting compliance," he says, "is not realistic." For example, Mr. Barnett drafted a letter to his physicians outlining the JCAHO requirement that all patient histories and physicals must be done and documented within the 30 days before surgery or they must be repeated, but he offered a grace period for physician compliance. "We told them we'd be asking each and every one of them to do this but that, after a 30-day grace period, no one would be allowed in surgery without it," he says. "No leeway. No wiggle room."

6. Keep Them Involved
Keeping physicians involved throughout the process can be a time drain, but it can be done efficiently if you take advantage of every opportunity, even passing encounters in the hallway. "One-on-one conversations are the single most effective way for me to involve key physicians," says Kay Kern, a nurse administrator with the Michigan Surgical Center in East Lansing, Mich. This works because physicians, just like anyone else, feel good when their opinions matter. Sandra Goodwin, a clinical nurse manager with Health Central in Ocoee, Fla., says her biggest mistake was writing policies and procedures and simply presenting them to the doctors. "They did not have a stake in the outcome," she said.

Finally, don't discount the value of follow-up. Keep the accreditation projects and the physicians' responsibilities fresh on their minds. "Asking them to do anything without good follow-up is catastrophic," says Marilyn K. Christian, the vice president of risk management and corporate compliance for Foundation Surgery Affil-iates, Inc., in Oklahoma City.

Ultimate outcome
If there is one common thread to all this advice, it is to keep the focus on patient care, and keep the focus consistent and strong. "Doctors are all of a like mind when it comes to providing quality patient care," concludes Ms. Roberts.