The Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE) adopted a policy promoting quality safeguards for ambulatory gastrointestinal endoscopy in February of 1994. These safeguards include the voluntary accreditation of ambulatory endoscopic facilities by one of the nationally recognized accrediting agencies, either the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or Accreditation Association for Ambulatory Health Care (AAAHC). This policy has wide-ranging implications for practicing gastroenterologists; this document is intended to facilitate the accreditation process for ASGE members who are involved in the governance of ambulatory endoscopic facilities. The rationale for adopting this policy is rooted in the ASGE's commitment to provide quality medical care, and to insure continuous quality improvement in that care. The Board felt that accreditation would improve performance and insure quality similar to that existing in the hospital. Additional goals included satisfying requirements of managed care organizations, care networks and purchasers of care, and serving as a method of compliance with state and federal regulations.
There are legitimate concerns among endoscopists that inadequately trained and poorly monitored physicians perform endoscopy without having met reasonable guidelines for training or facilities, such as those suggested by the ASGE. Accreditation might therefore discourage the performance of endoscopy by inadequately trained individuals in substandard settings. The Board felt that accreditation might also facilitate third party reimbursement, enhance risk management (and perhaps reduce insurance premiums), promote appropriate referrals, satisfy certain regulatory requirements, demonstrate a commitment to quality, increase public confidence, enhance the competitive position of legitimate endoscopic facilities, and promote professionalism in the ambulatory setting. The wisdom of adopting this policy has been recently confirmed in several communications with our members.
Ambulatory endoscopic facilities have recently been denied Medicare certification due to their lack of accreditation, and some third party payers have refused to pay facility fees to unaccredited ambulatory endoscopic facilities. It is likely that the linking of reimbursement to accreditation will continue and become increasingly more common in the future. It is therefore in both the member's and patient's interest that owners/operators of ambulatory endoscopic facilities take a proactive role in obtaining accreditation, rather than waiting until being denied reimbursement. The accreditation process may take considerable preparation and advance notice. It may take a year or more between the time a survey is requested and final accreditation is granted. The Governing Board is committed to facilitating this process, and is offering guidelines that will assist members seeking accreditation. While the complete process of review is quite lengthy and involved, this guide will outline the salient features of the review process and document the available resources for further assistance.
The two accreditation agencies, the JCAHO and AAAHC have a mission to improve the quality of care provided to the public. Their respective methods of accomplishing this mission differs somewhat, but include elements common to both. The origin of the AAAHC is from within the JCAHO, and it is reasonable to expect that both organizations will look similar to the surveyed facility. While the JCAHO has primarily been responsible for accrediting hospitals in the past, they have expressed a commitment to modifying and improving their accreditation process to meet the needs of the ambulatory health care community. Their reputation is that of being the “gold standard” for accreditaton. Their review is standardized and applicable to endoscopic facilities as well as to ambulatory surgical centers. The Joint Commission has sought counsel from the ASGE regarding issues specific to endoscopic facilities. In contrast, the AAAHC has primarily been engaged in accrediting ambulatory health care facilities. In this regard, they appear to be more focused on the accreditation needs of ambulatory endoscopy centers. While the differences between the two organizations are likely small, it appears that the manuals for the AAAHC are more user-friendly and less intimidating. Members of the ASGE have been working with both organizations and find that the review process is similar for each. It is the opinion of the members who have been surveyed that the process serves consultative and educational functions as well as evaluation and accreditation needs. The ASGE hopes to be able to provide even more assistance to members as more facilities are reviewed and more experience has been gained.
The JCAHO strives to accomplish its mission by determining whether or not an eligible organization complies with applicable Joint Commission standards, a process known as accreditation. The standards applied to health care organizations are statements of expectation that define the structures and processes that must be substantially in place in an organization to enhance the quality of care. JCAHO standards are divided into two categories: patient focused functions (5 standards) and organization functions (6 standards). These standards are briefly described below. It is impossible to convey the actual scope of the standard in a summary form, and review of the actual JCAHO manual is essential to determining compliance with any given standard.
Patient Focused Functions
The dimensions of performance in patient focused functions are comprised of doing the right thing (efficacy and appropriateness), and doing the right thing well (availability, timeliness, effectiveness, continuity, safety, efficiency and respect/caring). The applicable five standards are described below.
- Patient rights and organization ethics.
The goal of the patient rights and organization ethics function is to help improve patient outcomes by respecting each patient’s rights and conducting business relationships with patients and the public in an ethical manner. Patient rights activities and functions deal with access, treatment (including psychosocial, cultural and spiritual aspects, advance directives, active participation, conflict resolution, and care at the end of life), and respect (confidentiality, space, property, response to legitimate complaints, and communication). Organizational ethics activities and processes include conduct and conflict (disclosing ownership of referred services, contracts), code of ethics (marketing, admission, transfer, discharge, billing practices, providers, payers, and education institutions), organs (procurement and donation), research (addressing medication trials and existence of IRB when appropriate), and managing staff requests (establishment of policies and mechanisms to address any request by a staff member not to be involved in an aspect of patient care).
- Assessment of patients.
A goal of the patient assessment function is to determine what kind of care is required to meet a patient's initial needs and his or her needs as they change in response to care. The standards address the following processes and activities: collecting data (patient's physical and psychosocial status and health history), analyzing data and making care decisions.
- Care of patients.
The goal of the care of patients function is to provide individualized care in settings responsive to specific patient needs. The standards deal with planning care, providing care, monitoring and determining the outcomes of care, modifying care and coordinating follow-up.
- Education of patients and family.
The goal of the patient and family education function is to improve patient health outcomes by promoting healthy behavior and involving the patient in care and care decisions. The standards address promoting interactive communication between patients and providers; improving patients’ understanding of their health status, options for treatment, and the anticipated risks and benefits of treatment; encouraging patient participation in decision making about care; increasing the likelihood that patients will follow their therapeutic care plan; maximizing self-care skills; increasing the patient’s ability to cope with his or her health status; enhancing patient participation and continuing care; promoting healthy lifestyles; and informing patients about their financial responsibilities for treatment when known.
- Continuity of care.
The goal of the continuity of care function is to define, shape and sequence processes and activities to maximize coordination of care within a continuum. Some of the important activities and processes of the continuity of care function include planning the care process for patients, conducting patient assessments, development of a plan of care, determination of the most appropriate care setting for the patient, developing discharge planning, providing services, and providing continuing care which may include the transfer or referral to other settings or services.
These functions include six general standards as described below.
- Improving organization functions.
The goal of the improving organization performance function is to continuously improve patient health outcomes through essential processes such as process design, performance measurement, performance assessment, and performance improvement. The dimensions of performance are defined as doing the right thing and doing the right thing well as mentioned above, and focus on efficiency and appropriateness on the one hand, and availability, timeliness, effectiveness, continuity, safety, efficiency and respect/caring on the other.
The goal of the leadership function is for the organization's leaders to use the framework for establishing health care services that respond to community and patient needs. Effective leadership depends on the performance of the following processes and related activities: planning and designing services; directing services; integrating and coordinating services; and improving performance. The standards that address these processes and activities involve inclusiveness. These standards encourage staff participation and the development of leaders at every level who help to fulfill the organization's mission, vision and values; accurately assessing the needs of patients and other users of the ambulatory care organizations services; and developing an organizational culture that focuses on continuously improving performance to meet these needs.
- Management of the environment of care.
This focuses on providing a safe, functional and effective environment for patients, staff and other individuals in the organization. The applicable standards in this function deal with planning of space, equipment, and resources; educating staff about the role of the environment in safety and effectively supporting patient care; developing standards to measure staff and organization performance; and implementing plans to create and manage the organization's environment of care. Effective management of this environment includes using processes and activities to reduce and control environmental hazards and risks, prevent accidents and injuries and maintain safe conditions for patients, visitors and staff.
- Management of human resources.
This function focuses on identifying and providing the right number of competent staff to meet the needs of the patients served by the organization. In achieving that goal, the organization's leaders carry out the following processes and related activities: planning; providing competent staff; assessing, maintaining and improving staff competence; and promoting self-development and learning.
- Management of information.
This function focuses on obtaining, managing and using information to improve individual and organizational performance in patient care, governance, management and support processes. To achieve the goals of this function, the following processes are necessary: identifying information needs; designing the structure of the information and management system; defining and capturing data and information; analyzing data and transforming them into information; transmitting and reporting data information; and integrating and using information. Achieving that vision involves insuring timely and easy access to complete information throughout the organization; improving data accuracy; balancing requirements of security and ease of access; using aggregate and comparative data to pursue opportunities for improvement; redesigning information-related processes to improve efficiency; and increasing collaboration and information sharing to enhance patient care.
- Surveillance, prevention and control of infection.
This function focuses on identifying and reducing the risks of acquiring and transmitting infections among patients, employees, physicians and other licensed independent practitioners, contract service workers, volunteers, students and visitors. Surveillance, prevention and control of infection covers a broad range of processes and activities, both in direct patient care and in patient care support that are coordinated and carried out by the organization.
These represent an outline of the functions evaluated by the JCAHO at the time of the accreditation survey. For more complete descriptions of the performance standards, refer to the JCAHO publication: 1996 Comprehensive Accreditation Manual for Ambulatory Care.
The goal of the AAAHC is to facilitate cost-effective delivery of high-quality health care in ambulatory settings by providing a process by which providers can be publicly recognized for complying with standards of quality in a peer-based survey and accreditation process. They are committed to the concept that quality assurance and quality improvement are attainable by any health care provider, whether they be solo practitioners or practitioners in the largest medical groups. The standards include eight core standards common to all ambulatory care facilities and fourteen adjunct standards that may be unique to specific circumstances and are not necessarily applicable to ambulatory endoscopy centers. The standards are written in very general terms and significant latitude is given to facilties in meeting these standards in a fashion appropriate to the facility's specific situation. This encourages practitioner innovation and emphasizes the fluidity of the current health care delivery system. The standards of quality care are clear, but how they are attained becomes an individual challenge, not a prescribed one. Conversely, if the methods of achieving a standard are limited, the standards are stated in very specific terms.
- Rights of patients.
The organization being accredited recognizes the basic human rights of patients. They are treated with respect and dignity; the right to privacy and confidentiality is protected; they are given complete disclosure of the diagnosis and treatment options and are able to participate in the health care decision process. These rights as well as others are available to both staff and patient. Patients are also informed of their right to change primary or specialty physicians if others are available. Marketing or advertising regarding competence is not misleading to the patients.
The organization being accredited has a governing body that sets policy and is responsible for the organization. This means that the organization is legally constituted and has formal written charters, articles of incorporation, and various partnership agreements. The governing body is fully responsible, either directly or by professional delegation, for the operation and performance of the organization. They are responsible for determining the mission, insuring adequate facilities, establishing organizational structure, adopting by-laws, adopting policies and procedures, assuring quality of care, reviewing legal and ethical issues, maintained effective communication, and establishing a system of financial management. The governing body also provides for full disclosure of ownership in the ambulatory care facility. It is also the responsibility of the governing board, either directly or by delegation, to assign clinical privileges based on professional peer evaluation. This responsibility includes the credentialling of the health care practitioner and includes the responsibility for primary verification either directly, or through an independent credentialling process.
The organization being surveyed is administered in a manner that insures the provision of high quality health services and fulfills the organization’s mission, goals and objectives. Administrative policies, procedures, and controls are established and enforced. Qualified management personnel are employed, short and long range planning for the needs of the organization are implemented, and fiscal controls are implemented. Personnel policies are also established by the administration in order to facilitate attainment of the mission, goals, and objectives of the organization. Job descriptions, personnel qualifications, performance reviews, compensation, and the responsibilities and privileges of employment are enumerated and made known to the employee at the time of employment. The administration is also responsible for assessing patient satisfaction with the services and facilities provided by the organization.
- Quality of care provided.
The accreditable organization provides high quality health care services in accordance with the principles of professional practice and ethical conduct and with concerns for the cost of care and for improving the community’s health status. This broad responsibility implies that all heath care practitioners have the necessary and appropriate training and skills and practice their profession in an ethical and legal manner. Assistants are properly trained, qualified and supervised, and are available in sufficient number for the care provided. The provision of high- quality health care services is demonstrated by patient education, accessibility and availability of the health service, timely diagnosis, treatment consistent with the clinical impression, appropriate and timely consultation, the absence of clinically unnecessary diagnostic or therapeutic procedures, continuity of care, provision for services when the organization’s facilities are not open, complete clinical record entries, and patient satisfaction. When clinically indicated, patients are contacted as quickly as possible for follow-up of abnormalities and when the need arises, patients are transferred from the care of one health care practitioner to another. Concern for the costs of care is determined by the absence of duplicative diagnostic services, the appropriateness of treatment frequency, the use of the least expensive alternative resources when suitable, and the use of ancillary services consistent with the patient’s needs.
- Quality management and improvement.
In striving to improve the quality of care and to promote more effective and efficient utilization of facilities and services, the organization maintains an active, integrated, organized peer-based program of quality management and improvement that links peer review, quality improvement activities and risk management in an organized, systematic way. The organization’s professional and administrative staff understand, support and participate in programs of quality management and improvement at all levels. The review of clinical activities is peer-based and the results of peer-based review are brought to the attention of the governing board of the facility and there is a mechanism by which the governing board review is brought back to the staff involved for implementation of governing board policy. Additionally, there is a quality improvement program which addresses important problems or concerns in the care of the patients, reviews unacceptable or unexpected results, reviews clinical performance, implements measures to resolve important problems, and reports the organization’s findings to the chief executive officer and the governing board. The governing board is then responsible for implementing activities to improve the quality of care. The organization also maintains a program of risk management appropriate to the organization.
- Clinical records.
The organization maintains a clinical record system from which information can be properly retrieved. The records are legible, documented accurately in a timely manner and readily accessible to health care practitioners. There is a system that the organization must develop and maintain for the collection, processing, maintenance, storage, retrieval and distribution of patient records. Confidentiality of the records must obviously be assured; there is an individual designated to be in charge of clinical records, who has the responsibility for implementing the record policy of the organization. The necessary medical information must be in the records in an appropriate time frame, and medical advice by telephone is entered into the patient records and acknowledged by the health care provider. Research activities are clearly separated from nonresearch related care. Information regarding informed consent is also incorporated into the patient’s medical record.
- Professional improvement.
The accreditable organization strives to improve the professional competence and skill as well as the quality of the performance of the health care practitioners and other professional personnel it employs. The organization will therefore provide for the convenient access to library services, adequate orientation of personnel, the encouragement of participation in seminars, workshops, and other educational activities, and the organization provides a monitoring function to assure the continued maintenance of licensure and/or certification of the professional personnel.
- Facilities and environment.
The ambulatory endoscopy center provides a functionally safe and sanitary environment for its patients, personnel, and visitors. The organization complies with state and local building codes, state and local fire prevention regulations, federal regulations, is inspected annually by local and state fire control agencies, contains fire fighting equipment, has appropriate signage, has emergency lighting, and has stairways protected by fire doors. Additionally, the organization is responsible for the periodic instruction of all personnel in the proper use of safety, emergency, and fire extinguishing equipment, has developed a comprehensive emergency plan with which the personnel is familiar, and has personnel trained in cardiopulmonary resuscitation and the use of cardiac emergency equipment present in the facility during hours of operation. The facility also provides appropriate reception areas, toilets, telephones, parking, handicapped accommodations, adequate lighting, food snack services, and a system for proper identification, management, handling, transport and treatment of hazardous waste. Additionally, equipment is maintained and periodically tested and emergency power is available in the procedure and recovery areas.
- Adjunct standards.
There are a number of standards relating to the anesthesia services, surgical services, overnight care, dental services, emergency services, pharmaceutical services, pathology and laboratory services, and diagnostic imaging services among others, that may have no bearing on ambulatory endoscopic centers.
"As with the JCAHO standards, this overview is a summary and may not accurately reflect the scope or depth of the AAAHC standards in any given area. More information may be obtained by reviewing the handbook provided by the AAAHC document Accreditation Handbook for Ambulatory Health Care."
The preceding information is intended only to provide general information and not as a definitive basis for diagnosis or treatment in any particular case. It is very important that you consult your doctor about your specific condition.