SDS Accreditation Update
Credentialing & QI pose challenges for office programs
Documentation and policies are not always prepared for a survey
Reviewing the standards requirements, poring over checklists, and preparing staff members for survey questions may be standard procedure for all outpatient surgery programs that prepare for accreditation surveys, but office-based programs face certain challenges that hospital-based and freestanding outpatient surgery programs don't encounter.
The small staff and the few physicians involved in the office-based surgery programs mean that they have not had to think in terms of credentials, privileges, or ongoing quality improvement, points out Scott Trimas, MD, chief medical office of Atlantic Surgery Center in Jacksonville Beach, FL, and a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC).
"Governance and quality improvement are the two chapters that present the greatest challenges for office-based surgery programs," he says. Credentialing and privileging activities fall under the "governance" chapter, and physicians are not accustomed to verifying their own credentials and granting themselves privileges, Trimas explains. "Even if there is one physician in the practice, and he or she has been in practice for many years, the surveyor will look for documentation that primary source verification of credentials has been performed."
Documentation also must be in the physician's file showing what privileges are allowed in the office-based surgery suite, he says. "Younger physicians are not as surprised by these requirements for documentation, but physicians who have been in practice for longer periods of time may just assume that if they've been granted hospital privileges, that is all they need to show," Trimas says. However, the office-based surgery program must have a clearly written policy stating how credentials will be verified, how updates to licenses and certifications will be obtained, and how privileges will be granted within the office-based practice, he adds.
Once the policies are developed and the activities to verify credentials and grant privileges have been performed, be sure to indicate the actions taken in your governing body minutes, Trimas advises. "Even if you've done what you must do, it has to be presented to and approved by the governing board," he adds.
Peer review also can be an overlooked aspect of accreditation requirements, says Trimas. "It does not have to be a complicated process, but it must be physician to physician," he says. In a single-physician practice, the surgeon can choose any other physician to conduct peer review activities, even if the surgeon is in a different specialty, he explains. "A cosmetic surgeon can have an internist or a general surgeon review cases, and vice versa," he says.
QI is more than outcomes
Another challenging area for office-based programs is quality improvement, Trimas says.
"Many physicians think that if their outcomes are good, there is no need to conduct quality improvement studies," he says. "What they don't realize is that quality improvement is not just about good outcomes; it is about constantly looking for ways to improve," Trimas explains.
The surveyor from the Joint Commission on Accreditation of Health Care Organizations who visited East Cooper Plastic Surgery in Mount Pleasant, SC, praised the program for its quality improvement program, says Gail Lanter, CPC, administrator of the program. "Our projects that we conducted on infection control and post-op infections were very in depth," she says. "We also demonstrated that we shared the information with staff members and followed up with changes to improve our results," she adds.
Standards related to emergency preparedness and environment of care issues must be thoroughly understood, says Syed Ishaq, national director of the accreditation and consulting division of Somnia, a New Rochelle, NY-based anesthesia, pain management, and consulting firm for outpatient surgery providers. "Office-based surgery practices must look closely at safety and security processes and carefully document the drills that take place," he says. Standardized forms such as checklists for emergency drills should be used to make sure that all of the procedures described in policies are conducted, he suggests.
Be sure you understand how many emergency drills you need to perform, points out Trimas. AAAHC requires a minimum of four emergency drills each year, he explains. "This means four within the year, not three one year and five the next year to average out to four," he says. Schedule your drills well ahead of time to make sure that you don't miss scheduling one, Trimas suggests.
Joint Commission requires an office-based surgery practice to test the response phase of its emergency management plan once a year, in response to an actual emergency or in planned drills, according to Elizabeth Zhani, spokeswoman for the Joint Commission.
Trimas recommends that office-based practices take advantage of annual inspections by local fire departments. AAAHC does require annual inspections by local fire departments; thus, even if you are leasing space in a building where the building owner isn't required to obtain an inspection, the office-based practice should ask for the inspection to be sure it is conducted, he suggests. While the fire department is there, you can test fire alarms and ask for the department's cooperation in signaling them for fire response, sources say. The fire department can witness the signaling and record the time that it takes as part of their inspection, they say. Also, managers can ask fire officials for suggestions on safety and evaluations. Additional, firefighters or fire extinguisher service company representatives can demonstrate how to properly use extinguishers.
Joint Commission does not require an annual fire department inspection specifically for the accreditation survey because local or state requirements as well as Life Safety Code requirements call for the inspection, says Zhani.
Fire departments will perform the inspections, but you have to remember to ask for them, Trimas says. Plan for this inspection early in the year so that you don't forget to do it, he adds.
Because office-based programs have small staffs, many choose to use a consultant to help them prepare for their initial surveys, says Ishaq. While the consultant can provide tools such as checklists and sample policies, do not expect the consultant to do all the tasks needed to prepare, he warns. Staff members should plan on learning the new policies, if any are added, knowing emergency plans, and understanding the questions to expect during the survey, he says. "I'm not the one that will be asked questions by the surveyor," says Ishaq. "If I do all of the work, how will the staff members know the answers to the surveyor's questions?"
Sources
For more information about office-based surgery surveys, contact:
- Syed Ishaq, National Director of Accreditation and Consulting Division, Somnia, 10 Commerce Drive, New Rochelle, NY 10801. Telephone: (877) 476-6642 or (914) 637-3510. Fax: (914) 633-3287. E-mail: [email protected].
- Scott Trimas, MD, Atlantic Surgery Center, 1361 13th Ave. S., Jacksonville Beach, FL 32250. Telephone: (904) 249-2580. E-mail: [email protected].
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