Preparing for an accreditation survey: 3 insights from ASC experts

Three accreditation experts weighed on ASC accreditation challenges and opportunities in interviews with Becker's ASC Review.

Three key insights:

1. Emergency preparedness. Quality improvement includes several elements, and not all are intuitive, said Naomi Kuznets, PhD, vice president and senior director of the Institute for Quality Improvement for the Accreditation Association for Ambulatory Health Care.

"Credentialing and privileging has to be done at certain intervals," she said. "A specific number of emergency drills also have to be completed at certain intervals in addition to the requirement of documenting how the emergency drill proceeded and any need for corrective action to improve the drill. Medication reconciliation and allergy documentation must be done at every visit and should be done in the same place in the patient record every time."

2. Preparation. American Surgery Center was accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. The ASC's chairman, Kemal Erkan, explained how the center prepared and shared tips for others undergoing a similar process.

"After identifying variances, we developed policies and procedures to align with the standards," he said. "We educated staff members and kept them engaged with implementation and quality improvement programs. Fortunately, we have seasoned surgeons in the specialty, and therefore we were able to meet the program's caseload requirements."

The center has also been part of an accountable healthcare organization, where it has provides team-based integrated care. The organization has a dedicated care coordination team, and care is delivered in a culturally competent and patient-centered manner.

"Our commitment to our patients is to provide them with individualized care," said Mr. Erkan. "Our current process allows us to accomplish this by conducting weekly case conferences wherein our clinical and administrative leadership team, care providers and care coordination team intricately review each case and ensure that patients are receiving quality care throughout the process."

3. Sharing the workload. Tess Poland, RN, MSN, AAAHC's senior vice president of accreditation services, weighed in on the importance and significance of the association's advanced orthopedic certification in the increasingly crowded ASC market, as well as how to achieve the certification.

"Assign different tasks to your core leaders to oversee," she said. "Also, make sure you can pass a comprehensive assessment of your processes, policies and procedures, as well as anything else related to the certification standards. Once you've done that, develop an action plan and commit to weekly progress meetings until compliance in all standards has been achieved. That's important, because this program raises the bar for quality of care and patient outcomes."

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