Gaining & Maintaining Accreditation is Tough

Accreditation is a personal matter. Leaders of every ambulatory surgery center (ASC) have their reasons for or against it, and one accrediting body may work better for one facility than for the next. Timing is also important. Now might not work, but next year? The answer is up to the leaders of each business.

Some people, however, swear by accreditation. The process improves patient care, says Alan Gold, MD, a board-certified plastic surgeon and president of the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), which has accredited about 1,200 facilities.

ASC leaders should ask themselves the following question when considering accreditation, he says: “Do you need a cost-effective, ready-made patient safety initiative that centralizes hundreds of quality control elements that will help you focus on quality patient care?”

• Several other inquiries are helpful, says Michael Kulczycki, MBA, executive director of the Joint Commission’s Ambulatory Care Accreditation Program. He recommends asking:
• What is the climate in the local healthcare community toward accreditation?
• Will accreditation differentiate your ASC from other providers, either freestanding or hospital-based?
• Is accreditation consistent with your individual center’s philosophy, or that of your corporate owner or management firm?
• How do your payor networks view accreditation?

Why Bother?

Accreditation demands that a center and its staff meet important industry standards and it shows a commitment to patient safety, says John Burke, PhD, executive director and CEO of the Accreditation Association for Ambulatory Health Care (AAAHC). The AAAHC has accredited almost 1,800 ASCs.

“Unaccredited organizations — even excellent ones — have nothing to mark themselves against,” Burke says. “AAAHC accredited organizations are held to the highest standard of patient care.”

The certificate involves more than prestige and a piece of paper.

“There is significant value in the consultative and educational process that precedes the awarding of the certificate,” Burke says. “The self-analysis, peer review and consultation inherent in the process helps an organization improve its care and services.”

Indeed, a worthy accrediting process combines self-inspection, peer review and third-party inspection, and all of that can lead to better education and public relations, Gold says.

“Not every facility is accredited; it is something that dramatically sets a facility apart,” he adds. “It immediately installs a patient safety initiative that educates the staff, physicians and patient. AAAASF’s main concern is patient safety, but accredited facilities do carry a badge of honor that will enhance their marketability.”

No Choice in the Matter

For the most part, accreditation is voluntary, but requiring accreditation is gathering speed, particularly with governing bodies.

“CMS (Centers for Medicare & Medicaid Services) has given enormous value to the accreditation inspection process as they have reduced the number of inspections that they will perform and encourage physicians to seek out one of the deeming authorities (which includes AAAASF) for their Medicare inspections,” Gold says.

According to Burke, 25 states and the District of Columbia require or recognize accreditation of certain types of ambulatory surgical facilities. These states include Arizona, California, Delaware, Florida, Georgia, Indiana, Kansas, Maryland, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia and Wyoming.

Accreditation is more important in the states that use accreditation in lieu of state licensure or other regulations. There are more than 20 at this time, and leaders in Colorado and Washington are considering following suit, Kulczycki says.

“Mandates for accreditation are popping up more frequently at the state level for office-based surgery practices,” he adds.

Maintaining Accreditation

There are many reasons to maintain accreditation, and one of them is that an increasing number of third-party payors are attaching accreditation to reimbursement, says Patricia Marques, RN, RVT, FSVU, the accreditation services director for SurgiSYS. SurgiSYS staff members help attain accreditation for facilities that offer vascular, radiology and echocardiography labs.

“Facilities can ensure reaccreditation by utilizing a quality assurance program to record, analyze and retain all data required for reaccreditation,” she says. “This streamlines the reaccreditation process.”

Typically, organizations do not require more merits every year in order to maintain accreditation, but they do require facility staff to keep up with revisions of standards, Burke says.

“In terms of different levels of accreditation, if an organization is partially compliant — meaning they are compliant with a majority of the standards but still have some work to do — they may be granted a one-year or six-month accreditation term,” Burke says. “During this time, AAAHC expects these organizations (to) come into compliance. We will come back and re-survey the organization once the time period is up. If an organization fails to meet the majority of AAAHC’s standards, they are deferred.”

Maintaining accreditation is required in some states, and is therefore very important, Gold says. At the AAAASF, standards can change from year to year, but the organization does not make it more difficult to maintain accreditation than it was to acquire it. AAAASF offers three accreditation levels, based on the type of anesthesia delivered, Gold says.

AAAASF accreditation maintenance requires a self review. This is done with the help of a user-friendly booklet that is also used by inspectors, Gold says. Actual inspections are completed on a three-year cycle and self-inspections are required in the second and third years of accreditation. Fees are charged on an annual basis, he adds.

As for the Joint Commission, the accrediting body offers one level of accreditation, and it remains the same for first-time customers as for re-survey customers.

“Third party payors regularly use Joint Commission’s ‘QualityCheck’ to review the current accreditation status of its ASC network participants, so maintaining accreditation is critical,” Kulczycki says.

The Joint Commission has redesigned its accreditation as a continuous process vs. a once-every-three-years test, he adds. Joint Commission accreditation maintenance can be managed by:

• submitting annual self-assessments via secure electronic extranet to assess standards compliance 
• staying on top of policy or standards changes with the complimentary newsletter, Joint Commission Perspectives 
• seeking advice from the assigned accreditation account representative

Challenges

Accreditation is a process that can be time consuming, burdensome and frustrating, according to the SurgiSYS Web site.

“The same issues are faced by all facilities during the accreditation process, and that is accumulating all of the information required for submission of the accreditation application,” Marques says. “Most facilities do not have this data in one central location and must retrieve it from many areas, which makes the process very laborious.”

Initial challenges may form because of the development, implementation and organization of policies and procedures, Gold says. “The accreditation process forces the entire staff to pay close attention to detail and comply with a set of standards,” he adds. “It presents a team goal for the staff: an educational forum that will enhance patient safety and care.”

Any accreditation worth the paper it’s written on takes time and resources to complete. Most programs cover many topics thoroughly. The AAAHC, for instance, includes: governance, administration, quality of care, management and improvement, clinical records, health information, facilities and environment, and patient rights. AAAHC-accredited ASCs must be compliant for all the services they offer. These 16 adjunct chapters include anesthesia, emergency services, pathology and lab services, overnight care services and others, Burke says.

“Because such a variety of specialty organizations can fall under the ASC umbrella, it is the organization’s responsibility to ensure that all adjunct chapters that apply to the organization are met,” he adds.

Should Ailing Centers Get Accredited?

If an ASC has high standards and does good work but isn’t bringing in bucks, should the leaders of that facility bother with accreditation? Will it help turn the center around, or snow it under? The answer depends on the facility. It can sometimes be, “yes,” says Kulczycki.

“Many of the standards are related to focusing on the patients’ needs (for pre- and post-education, for relief from unacceptable levels of pain, to appropriate follow up care),” Kulczycki says. “These may be areas (in which) an ailing center desires improvement, and accreditation can assist one’s efforts in improving those results.”

Joint Commission accreditation does not require outside resources, he adds. It is based on the philosophy of constant readiness. And while patient care is number one, the bottom line matters too. In 2006, Joint Commission accountants started billing annually for a portion of the overall accreditation fee, instead of in one lump sum.

“Finally, for a struggling ASC, Joint Commission (leaders have) identified a number of liability providers who provide financial consideration for achievement of accreditation by ASCs,” Kulczycki adds. “In 2007, we launched a Web site that provides contact information for those liability providers who recognize accreditation.” That address is www.jointcommission.org/BusinessCommunity/liability_insurers.htm. 

As for the AAAHC, its national standards help ailing centers align their business practices to national standards, which ultimately results in better patient care, Burke says. “Accreditation is worth the investment not only to provide the best in patient care, but also in what’s in it for the organization,” he adds.

The benefits include:

• an accreditation certificate 
• the creation of a template for reviewing, recording and documenting practices 
• accreditation news and resources. These tools teach about state laws and regulations and show ASC leaders how to promote accreditation at the local level 
• access to education and networking through seminars that the AAAHC offers four times a year 

The AAAHC also gives accredited facilities access to benchmarking data. “Study findings can help you enhance your services by learning how to better meet standards put forth by the AAAHC, as well as how patients experience their quality of the care,” Burke says.

Common Mistakes

The accreditation process is not a panacea and troubles can occur along the way. Kulczycki recommends that people keep a realistic focus by following certain tips. First of all, leaders sometimes assign accreditation responsibility to an “accreditation coordinator” and abdicate ownership of the process. This is a no-no. “Accreditation is a ‘staff team-sport,’” Kulczycki says. “ASCs who are successful engage staff — both caregivers and business — and physicians in the process.”

Another flaw is that physician-owners sometimes wrongly assume that they are compliant with accreditation standards just because they provide high quality patient care. “Joint Commission standards focus on systems to plan, assess, implement and evaluate,” Kulczycki says. “Accreditation is so much more than (quality assurance).”

People should not assume that accreditation is only about written policies and procedures. “While some requirements look for written documentation, the survey process and standards expectations are focused on implementation and evaluation, not the paper planning document,” he says.

Another mistake ASC leaders make is to assume that surveyors arrive at the ASC with a ‘gotcha’ mindset, Kulczycki says.

“As ambulatory clinicians and managers in real life, the Joint Commission surveyors bring education and consultation to the survey process,” he adds. 

Bariatric Accreditation Program Holds Centers Accountable for High levels of Patient Care

By Michelle Beaver

As American waistlines grow, so too must the standards for bariatric surgery. One accrediting body, for example, holds bariatric surgery centers to high expectations of patient care, program leaders say.

The American College of Surgeons (ACS) offers the Bariatric Surgery Center Network (BSCN) accreditation program. The requirements are based on physical resources, staffing, clinical standards, surgeon credentialing standards, data reporting standards, etc.

“Scrutiny of contemporary weight loss surgery reveals a need for organization, standards and data on outcomes,” the ACS Web site claims. The decision to recommend surgery for obese patients requires multidisciplinary input, it adds.

The program offers accreditation for four levels of inpatient facilities, and for two levels of outpatient facilities. One level is called “provisional approval” and the second is called “full approval.”

To gain provisional approval, the center administrators must first send a completed application and a letter of support from their chief executive officer to the Bariatric Advisory Committee (BAC). If all is well, the BAC members send various agreements; the centers’ leaders review them and send a program fee to BAC. Then, if the materials pass muster, BAC members send a letter that grants provisional approval, and a questionnaire in preparation for a site visit review.

For full approval, center administrators wishing to gain accreditation must complete and submit a “pre-site review questionnaire,” and schedule a site visit within six months of provisional approval. An ACS site visitor reviews the facility, and then a “final site visitor report” is turned into the BAC members for review. If all standards are met, the center receives the “ACS BSCN Certificate of Accreditation.”

Representatives claim there are several benefits to the program, including: 

• demonstration to bariatric patients and the medical community that your bariatric surgery center provides the highest quality care 
• having accessible bariatric surgery data for clinicians, third-party payers, managed care organizations, and the general public 

Also, eligible patients who seek bariatric surgical care in fully approved “level one” facilities may qualify for coverage from the Centers for Medicare & Medicaid Services (CMS), the Web site claims.

Bariatric accreditation is slowly gaining recognition among patients and insurers and may one day become important in high-competition markets, says Kent Sasse, MD, MPH, FACS. Sasse is medical director of Western Bariatric Institute in Reno, Nev., and is author of, “The Sasse Guide to Outpatient Weight Loss Surgery.”

The process of seeking accreditation can be time-consuming, expensive and laborious for staffs, and even some outstanding centers can’t always afford to seek accreditation, Sasse says. But even so, if insurers and patients highly regard the accreditation process, it will gain speed.

The American Society of Metabolic and Bariatric Surgery also recognize ASCs in their programs, Sasse says.

“I believe there are many highly qualified programs across the country with highly trained surgeons and comprehensive programs,” he adds. “Are there enough? Not all of these centers are well integrated with an ASC. I predict the demand for outpatient weight loss surgery will rise significantly in the future, so we may soon see increased demand for high-quality bariatric centers integrated with ASCs.”

Bariatric services are indeed becoming more important as the American obesity epidemic increases. Bariatric patients are no longer a segregated part of the patient population, says Helen Kerr, a Sittris principal who designs chairs for obese patients.

“About a third of all patients weigh 350 pounds or more,” Kerry says, “and they are present in every sector of healthcare. All furniture and spaces need to acknowledge and accommodate the special ergonomic needs of these patients.”

That goes for standards too.