Maintaining Accreditation – Tips for Getting through a Survey

Recently, AAAHC polled a group of highly experienced surveyors regarding the most common areas of deficiency that they encounter during accreditation surveys. Although the surveyors polled work for AAAHC, these concerns also likely reflect common deficiencies seen by all of the accreditors. The responses included the following:

Credentialing - A frequent error is the failure to credential all providers at a facility, including anesthesiologists, surgeons and nurse anesthetists. All-too frequently, organizations rely on outside information and do not do their own credentialing. To avoid this pitfall, AAAHC standards require that each organization have a formal program that documents the licensure and education of their providers.

Peer Review - Random chart review – sometimes performed by non-peers – is not enough. Peer review should be performed by true peers; for example, AAAHC standards require that single-physician facilities enlist another physician for peer review. If centers have more than one physician they may review each other. Surveyors also say that peer review often does not include outcomes monitoring. There should be documentation in the credentials files or governing body minutes that the results of peer review have been used to determine continuation of clinical privileges.

Quality Improvement - Quality monitoring is often confused with QI studies. Ambulatory health care providers should conduct studies that address quality problems, and administrative and clinical personnel should be involved in QI activities.

Benchmarking - Many centers do external benchmarking, such as conducting comparisons of area and national benefits, wages, PTO, insurance and so forth, but fail to create an internal benchmarking study based on the data collected. Others do no benchmarking at all.

Patient Privacy/Rights and Safety - Some organizations fail to delineate patient responsibilities along with patient rights, while others fail to inform patients of mechanisms for expressing grievances. Among the most serious mistakes are those that fail to adequately maintain patient privacy and confidentiality.

Preparing for the Accreditation Survey - Organizations will sometimes fail to carefully review accreditation standards before the survey takes place, or provide inaccurate information on the survey questionnaire.

Policies and Procedures - Organizations may use policies originally created by consultants or other ambulatory health providers, but fail to personalize them to fit their individual needs. In other cases, the governing body of the organization may fail to document its reviews and actions as required by the standards.

Suspensions - Failure to notify the accrediting body about a physician’s or an organization’s suspension or other legal action may result in accreditation being denied or revoked.

Authenticating Reports - Many facilities do not authenticate lab, x-ray or pathology reports before they are filed, failing to verify that the provider has reviewed the results. A physician’s signature is necessary before such documents are filed.

Miscellaneous - Forgetting to perform and/or document annual drills and fire inspections, and failure to develop a written policy for assessing and managing acute pain are common errors seen by surveyors.

A recent Becker’s ASC article describes 10 Critical ASC Accreditation and Patient Safety Challenges and mitigation strategies to surmount them.

1. Patient identification and universal protocol documentation.
2. Adherence to CMS's new Conditions for Coverage regarding infection control.
3. Accurate current medication lists.
4. Ensuring current patient history and physicals.
5. Tracking post-operative complications and infections.
6. Continually evaluating and improving performance.
7. Requiring true peer reviews.
8. Transitioning care between providers.
9. Maintain compliance and proper training.
10. Use tools available for patient safety.

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