An increasing number of ambulatory surgery centers are undergoing accreditation to improve their level of care, gain more clout with payers, and increase credibility with physicians and patients. But as all who've attempted accreditation know, the process is costly and time-consuming, and even though few facilities fail completely, most obtain only partial compliance, requiring them to be re-surveyed in six months to a year. There are some facilities, however, that do get everything right the first time and achieve the elusive three-year status.
So, what sets these facilities apart? To find out, we interviewed two administrators who recently helped their facilities ace the accreditation process with the Accreditation Association for Ambulatory Health Care (AAAHC). In this article, Lisa Robinson of the Houma Outpatient Surgery Center, a multispecialty facility in Metarie, La., and Cindy Groce of Academy Orthopedics, a single-specialty orthopedics facility in Cumming, Ga., share some simple secrets of their success.
Start early
Most experts advise obtaining the standards manual and starting preparations at least six months to a year in advance, and both facilities took this to heart. Academy Orthopedics filled out the pre-survey questionnaire in October 2002 and spent six months preparing for their survey, which occurred in April 2003. For the Houma ASC, preparations started even before Ms. Robinson was hired in August 2002; the survey didn't occur until April 2003.
An obvious benefit of starting early is that it allows more time to break up the work into manageable parts. "If you have a year to prepare and you need to revise your policies and procedures, you can divide your policy manuals into roughly twelve parts and tackle one part per month," says Ms. Robinson.
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JCAHO's 2003 Top Requirements for Improvement
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Achieving 100 percent compliance with all of JCAHO's standards isn't easy. To help facilities focus on the areas where they're most likely to be deficient, JCAHO's Department of Standards and Research releases an annual list of the "Top Requirements for Improvement," which consists of the standards with which facilities are most likely to be non-compliant. We asked Michael Alcenius, associate director of JCAHO's Standards Interpretation Group. to explain exactly how facilities fail to come up to par on each of these directives. For more details on how to fix what's wrong, or maybe only half-right, consult your standards manual.
HR.7.1 Applying credentialing criteria uniformly for LIPs (Licensed Independent Practitioners)
This standard lists four core criteria for credentialing: current licensure, relevant training and experience, evidence of current competence (professional references) and evidence of the ability to perform the requested privileges. But according to Mr. Alcenius, some facilities don't dig deeply enough, or at all, into an applicant's background before hiring him or her. "They don't contact the licensing board for verification, or they use unapproved credentialing organizations. In some cases, they don't get professional references, either," he says. "You have to thoroughly check to make sure individuals are who they say they are."
 Rate of noncompliance: 23 percent of facilities
HR.5 Assessing staff abilities to fulfill job expectations
HR.7.2.1 Granting clinical privileges based on practitioner's qualifications and the care provided by the organization
Some facilities never develop a specific list of privileges detailing the procedures that practitioners can perform in their ORs. "A facility may adopt a privilege list from a local hospital, which may include a complex procedure like coronary artery bypass graft, but there's no way the facility can host that procedure," says Mr. Alcenius. Even if a physician never performs this procedure at the facility, it's a violation to have it on the list.
Rate of noncompliance: 16 percent
PE.1.4 Assessing pain in all patients
Every facility needs to have a comprehensive pain assessment tool that qualifies pain based on character, frequency, location and duration. The JCAHO manual contains many resources to help facilities develop their own tools, which need to be age-specific (asking patients to score their pain on a one to 10 scale may be adequate for adults, but not for children). Most facilities assess pain somehow, but often the evaluation doesn't go far enough, according to Mr. Alcenius. For example, pre-op nurses may not screen for a baseline level of pain when patients first enter the facility.
Rate of noncompliance: 13.9 percent
PE.1.15 Conducting quality control checks on each procedure as identified by the organization
This standard specifically addresses blood glucometer and other CLIA waived lab tests. Facilities that perform these tests are required to run two quality control checks every day to ensure that their testing instruments are working properly. Most facilities instead follow the manufacturer's recommendations for quality control checks, not realizing that these recommendations are for home use, not professional use, says Mr. Alcenius.
Rate of noncompliance: 11.3 percent
PI.4.1 Using appropriate techniques to analyze and display data
Many facilities collect and analyze data for quality improvement, but they fail to present and display the data to its full advantage with pie charts, histograms and the like. "You should have a statistical package that displays your data properly," advises Mr. Alcenius. "It's much more effective to present a picture of your data rather than a list of numbers."
Rate of noncompliance: 11.3 percent
EC.2.1 Implementing the organization's safety plan
Most facilities have multiple safety plans, but often there's no real indication that staff members have had and are undergoing ongoing adequate safety training. OSHA has specific training requirements, and the JCAHO standard includes some additional ones, so facilities need to consult both organizations when developing their training plans.
Rate of noncompliance: 10.5 percent
HR.4.2 Using ongoing data collection about staff competence patterns and trends to respond to staff learning needs
Staff education programs need to be tailored to staff needs. Most facilities evaluate staff on a regular basis, but they don't assess where competencies may be weak and develop training programs to address those areas. "Facilities may be offering needlestick safety seminars, when what the staff really needs is to brush up on handwashing techniques," says Mr. Alcenius.
Rate of noncompliance: 10.2 percent
- Yasmine Iqbal
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Get everyone involved
At the Houma Outpatient Surgery Center, everyone on the staff of 25 people played a role in the preparations, according to Ms. Robinson. The staff divided into clinical and administrative teams, and each team was responsible for ensuring compliance with a portion of the AAAHC standards. There was a fair amount of crossover between the clinical and administrative sides, however, so eventually everyone was exposed to the entire AAAHC manual, and in the process they developed a new appreciation for their colleagues' roles.
The staff's attitude toward accreditation changed as well, according to Ms. Robinson. "At first the staff was nervous, but once they realized that the facility would be better as a result of going through this, everyone was excited to cooperate," she says. "Now, we're all better cross-trained, and we've also achieved a tremendous sense of teamwork, unity and pride."
Get your documentation in order
Most surveyors will probably spend a good part of the visit reviewing the facility's policies and procedures, patient charts and other documentation, and to prepare for this scrutiny, some facilities will have more work to do than others. Because Academy Orthopedics had developed most of their documentation to be specific to the facility, they "didn't have to redo a thing," says Ms. Groce. For Ms. Robinson's facility, updating and reviewing policies and procedures was more time consuming, but they looked at it as an opportunity. "The accreditation process obliged us to really dig deep into our documentation to make sure everything was complete and pulled together," she says.
Put your data to use
A common complaint of many surveyors is that facilities collect a lot of data, but they fail to show how they've analyzed that data and used it to improve quality of care. Neither of these facilities made that mistake.
The Houma facility, for example, collected data on post-op nausea rates, determined that they were high and discovered that part of the problem was that patients were unclear on when to take anti-nausea medication. They then took the next step and developed a better post-op instruction process. They also reviewed their supply costs and usage and used the data to support the switch to a different GPO, saving 30 percent a year in supply costs. Finally, by studying their policies on red bag trash and refining those policies, they were able to save $1,600 a month in hazardous waste disposal costs.
Academy Orthopedics also performed numerous benchmarking studies and met with physicians on a quarterly basis to discuss them. Neither facility performed studies just to have something to show the surveyors - they pinpointed issues specific to their facilities, collected data, and then used the data to achieve substantial improvements. The fact that that Q/A was required, however, did motivate them to go the extra mile. "We probably would have done these studies anyway," says Ms. Robinson, "but we wouldn't have drilled down to the level that we did."
Provide access and comfort for the surveyors
Both facilities went out of their way to make sure that the surveyors had full access to every part of the facility and everything they needed. They provided transportation to and from the facility, set aside rooms where surveyors could review documentation in private, brought in catered lunches and assigned staff to be on hand in case anything was needed. With such a short time to perform the survey (Houma's lasted a day and a half; Academy Orthopedics, only a day), these small steps let the surveyors stay focused and make maximum use of their visits.
Be open to suggestions
Both facilities adopted the attitude that the surveyors were there to instruct and inform, rather than criticize, and they were proven correct. "We felt that the surveyors were very understanding and fair," says Ms. Robinson. In addition to a balanced evaluation, both facilities received helpful suggestions from their surveyors. For example, a surveyor at the Houma ASC suggested that physicians' peer review evaluations be filed with their complete record, instead of a separate binder, to make sure that everything about each physician was in one location. He also suggested sending patient evaluations home with patients, instead of requiring them to be filled out at the facility. The facility has since seen an increase in the number of surveys returned. At Academy Orthopedics, the surveyor suggested that patient responsibilities, as well as patient rights, be posted in the waiting area to remind patients that they must play a major role in their own recovery.
Enjoy the outcome
The staffs at both facilities were elated when they learned of their accreditation status. "It was like getting degree - with honors - from Harvard!" says Ms. Robinson. They immediately sent out letters to the physician community, and they have since seen an increase in the number of physicians requesting privileges. Ms. Robinson also expects to have more clout with managed care plans in the future.
One of the main reasons Academy Orthopedics underwent the process was because Blue Cross Blue Shield, which covers about 21 percent of their cases, requires accreditation before they will pay a facility fee. "Two weeks after we got accredited, Blue Cross signed on," says Ms. Groce. She expects her bargaining power with other payers to increase, as well. The facility advertised its new status by prominently displaying its accreditation certificate and putting the AAAHC logo on the facility brochure.
Both facilities realize that maintaining compliance will be just as challenging as achieving it. At the Houma facility, they are already working on correcting the few areas in which they were in partial compliance. They also plan to participate in FASA's Outcomes Monitoring Project to collect benchmarking data for Q/A studies. Ms. Groce has also committed her facility to maintain a high level of quality. "You have to stay on top of everything daily," she says.
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How We Survived a Surprise Survey
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Anne Cole
Tinley Park, Ill.
"It'll never happen to us." That's the way we feel about many unlikely occurrences, including winning the lottery, getting struck by lightning and, at our multispecialty ambulatory surgery facility, undergoing a random, unannounced Joint Commission inspection. We'd always known that having surveyors show up unexpectedly was a possibility - since 1993 JCAHO has performed unannounced follow-up surveys on five percent of the facilities that undergo their standard triennial inspection. But we'd been surveyed by JCAHO for many years during our 18-year history, most recently in March 2001, and we thought our chances of being picked were pretty slim. That is, until the morning of May 20, 2003, when two surveyors showed up on our doorstep.
If you're a JCAHO member, you probably know that by 2006, all JCAHO surveys will be unannounced. Gone will be the days when facilities crammed frantically for survey day - soon you'll be expected to be 100 percent aware of and compliant with all JCAHO standards, all the time. Fortunately, our surprise inspection showed us that we are on the right track. Here's how we tackled that nerve-wracking day.
May 20th was a particularly busy day for us, with 21 cases scheduled. At 8 a.m., the day was well underway when our receptionist greeted our two unexpected guests, who produced badges and a document stating that they were from the Joint Commission. The receptionist immediately alerted our nurse manager, office manager and me. As the administrator, it was my responsibility to mobilize the facility and get the surveyors everything they needed while ensuring that our cases proceeded smoothly. The surveyors, who were specially trained in unannounced survey protocols, realized that business as usual had to continue; they also acknowledged that some key staff, such as our medical director, wouldn't be able to spend much time with them. They presented us with a very focused agenda that they could follow with minimal disruption to our other activities, including a documentation review, a tour of the facility and a summation meeting.
For the next four hours, the surveyors examined many facets of our documentation, including our policy and procedure manuals, performance improvement plans, medical committee meeting minutes and employee files. I stayed with them throughout the review, on the "hot seat," as they peppered me with questions about how our facility met certain JCAHO standards, how this was reflected in the documentation and how we had acted on the recommendations from our last survey. They grilled me on how we were meeting the safety standards and asked me to describe our patient identification and surgical site identification processes. They also asked specific questions about our staff competency and performance improvement programs, both of which we had expanded and improved in response to suggestions from our last JCAHO inspection. The surveyors moved quickly from one topic to another, and their questions were always brief, to the point and relevant.
Word spreads
After documentation review, the surveyors toured our facility for about three hours. By this time, word had spread that we were being inspected, and everyone was on alert. Here are some of the areas the surveyors looked into:
In the waiting room, they checked to make sure that our patient rights and responsibilities were prominently displayed.
In the pre-op area, they examined how we ensured patient confidentiality and privacy. They also spot-checked patient charts and lab orders.
In the supply areas, they checked for expired drugs and outdated supplies.
In the ORs, they observed a few ongoing cases. In between cases, they even looked into the nooks and crannies of the ORs, including the air filters.
Throughout the tour, the surveyors pulled aside and questioned various staff. For example, they asked one of our recovery room nurses to describe the steps she took to uniquely identify each patient. Similarly, they quizzed a scrub nurse on our policies for identifying and marking the surgical site for each case.
Following the tour, the inspectors withdrew into one of our conference rooms to review more documentation and discuss their findings. Our nurse manager, office manager and I then joined them for a summation meeting.
Phew!
To our great relief, we were told that we had done very well. The surveyors praised us for maintaining a high level of compliance and improving on areas that were flagged in our last survey, such as our staff competency program. They also had a few suggestions for us on how we could better comply with JCAHO standards: for example, they suggested that we lock up the anesthesia medication while our OR rooms were being turned over. Previously, we had only secured them after all cases were complete. The surveyors then presented us with a preliminary report showing that, just as with our last triennial survey, we had achieved a score of 97.
Having been through one surprise survey, I'm not particularly anxious to repeat the experience, but I'm very proud of how we came through. I think we succeeded because, as we've prepared for our other surveys, the JCAHO standards have become inured in our staff and in our procedures. We also hold monthly meetings to apprise the staff of all new standards and develop ways to meet them. There's some comfort in knowing that we won't be scrambling around to prepare for our next inspection - we're already living the standards every day.
Be forewarned - an inspection can occur any day, any time and there really are no major steps you can take to get prepared. But if you're acting on the suggestions from your last survey and committing your facility to delivering consistently high-quality care, you probably already are.
Ms. Cole ([email protected]) is the administrator of Ingalls Same Day Surgery Center in Tinley Park, Ill.
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