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Application and Survey Process

Initial application
Regardless of which accrediting body is chosen, the process of achieving accreditation is similar. All three organizations require submission of a written application prior to arranging an onsite survey. The application is extensive and typically requires that the organization assess its own compliance with the accreditation standards.

The AAAHC organizes its standards into chapters. The first eight “core” chapters apply to all organizations. The remaining adjunct chapters are applied based upon the specific services provided by the organization. For most AECs, chapters on anesthesia services, pathology and medical laboratory services, and surgical services will apply.

The JC applies different sets of standards for ambulatory health care, office based surgery, behavioral health care, hospitals, home medical equipment suppliers, laboratories, long term care, and home care. AECs are mainly evaluated under the ambulatory health care accreditation standards, which include environment of care, emergency management, human resources, infection control, information management, leadership, medication management, provision of care, performance improvement, record of care, rights and responsibilities, and waived testing.

AAAASF classifies standards based upon the type of anesthesia used. AECs that utilize opiate and benzodiazepines for sedation are Class B; these are differentiated from Class C-M organizations that utilize propofol. Under AAAASF standards, propofol may only be administered by a certified registered nurse anesthetist (CRNA) or anesthesiologist.

Survey
The duration and scope of the accreditation survey is determined by the size and complexity of the organization. Most single specialty AECs can expect a single surveyor who will conduct the survey in one or two days. Larger organizations or AECs that are part of a multi-specialty center may require two or more surveyors and a more extensive survey duration.

The JC conducts unannounced surveys for all organizations seeking re-accreditation after the initial accreditation period. Although the organization may request up to 10 days each year in which surveys should be avoided, the accreditor does not guarantee that these requests will be honored.

All of the accrediting bodies are required to conduct unannounced surveys as part of the Medicare deemed status program. The accreditor may also conduct an unannounced survey of an accredited organization if concerns have been raised regarding ongoing compliance with the accreditation standards. Random unannounced surveys are also performed for a small percentage of accredited organizations annually, for quality assurance purposes.

Standards for the three accrediting bodies are very similar in scope and areas of focus. All three seek to ensure patient safety and efficient operations by establishing guidelines for proper governance and administration, quality assurance, clinical recordkeeping, adequate and well-maintained facilities, anesthesia and procedural protocols, and peer review.

When surveying an organization, accreditation surveyors observe patient care; review the organization’s physical facilities, policy and procedure manuals, charts, personnel files, and other records; and speak with physicians and office personnel.

In addition, JC utilizes a unique “tracer methodology” in which surveyors follow the course of care, treatment, and services provided to individual patients as they move through various parts of the institution, from preadmission through post-discharge. As indicated in the Survey Activity Guide, surveyors directly observe the care provided to patients by staff, including physicians. JC surveyors are also expected to interview patients and their families about such issues the coordination and timeliness of services, understanding of discharge instructions, response time, and perception of services.

Accreditation decision
The standard term of accreditation is three years for all of the major accrediting bodies. AAAHC may award a one year accreditation when a portion of the organization’s operations are acceptable, but other areas need to be addressed and the organization requires time to achieve and sustain compliance with AAAHC standards. Such organizations must undergo a repeat survey within ten months of the original survey. AAAHC also awards six month accreditation to organizations that are not in compliance with standards, but demonstrate the commitment and capability to correct deficiencies within six months. A repeat survey is conducted within that time frame. AAAHC provides a right of reconsideration process to organizations receiving less than a three year accreditation term, and an appeal process for those whose accreditation is denied or revoked.

AAAHC views its surveyors as fact finders; final decisions regarding compliance with the standards and accreditability are made under the supervision of the Accreditation Committee. In contrast, the JC surveyors are empowered to make these determinations themselves. At the end of the on-site survey, the surveyor provides the organization with a report summarizing the survey findings. This report identifies standards which were scored as less than fully compliant. The organization then has 60 days to submit evidence that it has come into full compliance with the identified standards; for some standards, data-driven measurements may be required. Full accreditation is awarded if all deficiencies are satisfactorily addressed. If the deficiencies are not completely resolved, JC may award Conditional Accreditation, Provisional Denial of Accreditation, or a Denial of Accreditation. These decisions are immediately posted to the Quality Check website. The JC allows organizations to appeal a provisional denial of accreditation; however, once accreditation is denied, no further appeals are available.

AAAASF requires complete compliance with each standard to become and remain accredited. If deficiencies are found during the survey, however, organizations are given an opportunity to correct them prior to the final accreditation decision. A hearing process is in place for organizations whose accreditation has been denied or revoked.

Maintaining accreditation
The JC has the most stringent requirements for maintaining accreditation. Every twelve months, accredited organizations are required to submit a periodic performance review, which is a self-assessment to identify areas not in compliance with the standards. For all such areas identified, a written plan of action must be submitted and are reviewed by telephone consultation. An emphasis is placed on data-driven measures to support the performance improvement plan. In addition, as described previously, resurveys by JC are unannounced and may occur at any time between eighteen and thirty-nine months after the previous survey.

In contrast to the other accreditors, AAAHC does not require regular reporting by accredited organizations between surveys unless the organization has a significant change in operation. Organizations are required to notify AAAHC of any significant organizational, operational, or financial changes within fifteen calendar days.

AAAASF requires a facility inspection every three years. In between inspections, the facility director must perform a self-evaluation of the facility and submit a written standards and checklist answer sheet in order to maintain accreditation. Accredited facilities must notify AAAASF within thirty days of any change of ownership, and within five days of any death occurring either in the facility or within thirty days of a procedure performed in the facility.

All three accrediting bodies have provisions for immediate revocation of accreditation upon receipt of information regarding serious events, such as action by a state medical board or other regulatory body. Provisions also exist for emergency, unannounced surveys under certain exigent circumstances; for example, AAAASF requires such an investigation for any patient death occurring at the facility or within thirty days of a procedure.

- Lawrence Kim, M.D., FACG, AGAF

Member Feedback
If you have feedback or concerns for ASGE regarding accreditation please feel free to send your message or inquiry to the ASGE practice management e-mail address at practicemanagement@asge.org