Survey Process

Choosing an accrediting organization can be a complex and nuanced process. However, regardless of which organization you choose, the unifying accrediting organization factor is that each accrediting body requires that your applications are based on a uniform statement of nationally recognized guidelines. ASGE can be this unifying factor and supply the uniform statement of nationally recognized guidelines.

Regardless of which accrediting body is chosen, the process of achieving accreditation is similar. The following three organizations (AAAHC, JC, AAAASF) 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 Accreditation Association for Ambulatory Health Care (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 Ambulatory Endoscopy Centers (AECs), chapters on anesthesia services, pathology/medical laboratory services, and surgical services will apply.

The Joint Commission (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. These 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.

The American Association for Accreditation of Ambulatory Surgery Facilities (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.

The duration and scope of the accreditation survey are 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.

Each of these accrediting bodies is 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 performed annually as well (for quality assurance purposes) at a small percentage of accredited organizations.

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, the 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. The JC surveyors are also expected to interview patients and their families on these issues, including the coordination and timeliness of services, understanding of discharge instructions, response time, and perception of services.

ASGE guidelines are intended to provide direction and structure, by which units can develop their own policies and procedures that are setting- and unit-specific. While there are guidelines designed specifically for the endoscopy unit, such as those published by ASGE, most guidelines are broad and are not designed to be universally adopted.

 As part of the guideline adoption process, units must be aware of all aspects of the guidelines and must document which aspects of the guidelines are being adopted and which do not apply to the non-sterile environment of endoscopy.

Upon a Medicare survey, the surveyor must hold the unit accountable for the specific aspects of the guidelines which have been adopted, even if it is evident that some aspects were adopted in error.

Accreditation Decision

The standard term of accreditation is three years for each of the major accrediting bodies. AAAHC may award a one-year accreditation when a portion of the organization’s operations are acceptable, although 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, albeit 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 independently. At the conclusion of the on-site survey, the surveyor provides the organization with a report summarizing the survey findings. This report identifies standards that 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, the 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.

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 via telephone consultation. An emphasis is placed on data-driven measures to support the performance improvement plan. As described previously, resurveys by the JC are conducted 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 to maintain accreditation. Accredited facilities must notify AAAASF within thirty days of any change of ownership. Notification must also occur within five days of any death 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 (i.e., action by a state medical board or other regulatory body). Provisions also exist for emergency, unannounced surveys under certain exigent circumstances. As an example, AAAASF requires such an investigation for any patient death occurring at the facility or within thirty days of a procedure.

 

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 complete 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 - The purpose of Peer Review is to evaluate patient safety and the quality of care delivered by a provider. While it is common for organizations to focus on chart review this process can only provide verification of documentation and is typically unable to address the quality of care. A quality Peer Review program focuses on a more complete assessment including transfers, complications, adverse incidents, and incidents (Patient Safety), GIQuIC metrics (Quality of Care), chart review (Documentation), and patient complaints (Patient Satisfaction).

Quality Improvement (QI) - 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 conduct external benchmarking, including comparisons of area and national benefits, wages, PTO, insurance, etc. Centers often fail, however, to create an internal benchmarking study based on the data collected or do not benchmark 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, albeit fail to personalize them to fit their individual organizational needs. In other cases, the governing body of the organization may fail to document organizational reviews and actions as required by the standards.

Suspensions - Failure to notify the accrediting body regarding 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 any document is 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 Becker’s ASC article describes 10 Critical ASC Accreditation and Patient Safety Challenges and mitigation strategies to surmount them:¹

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. Maintaining compliance and proper training.
10. Using tools available for patient safety.

1. A statement should be made citing the ASGE references as recommendations from a nationally recognized specialty society that were used in the development of this reference.

2. If other nationally recognized society guidelines are also being used to develop policies and procedures, it is important to review those policies and reconcile differences so that contradictory policies are not developed.

3. The Association of Operating Room Nurses (AORN) has specific policies requiring surgical attire, staffing, and restricted areas that endoscopy facilities may not wish to adopt. In the interpretive guidelines, AORN’s standards are mentioned as an example of nationally recognized standards. CMS surveyors, therefore, may hold facilities to those standards unless they have specifically adopted others.

4.  Documentation of the adoption of ASGE guidelines should be referenced in the meeting minutes of the organization’s governing body. The reference should include the guideline, the portion of the guideline to be adopted, and an education plan for staff and providers as needed.

1. 10 Critical ASC Accreditation and Patient Safety Challenges and Best Practices to Overcome Them. http://www.beckersasc.com/asc-accreditation-and-patient-safety/10-critical-asc-accreditation-and-patient-safety-challenges-and-best-practices-to-overcome-them.html.