Accreditation of Ambulatory Surgery Centers

NOVEMBER 1999, VOL 70, NO 5 ‘Brown

Accreditation of Ambulatory Surgery Centers

A ccreditation of an ambulatory surgery center reflects a commitment to quality, patient- centered care and to excellence in the ambulatory surgery specialty area. By successfully completing the accreditation process, a

facility demonstrates to the public, its patients, and other health care professionals that it provides exemplary ambulatory surgical care. In 1997, the United States had more than 1,000 accredited centers.’ These facilities voluntarily pursued accreditation because they wanted to give patients the highest quality medical care. In return, accreditation has given these facilities opportunities to participate in networking, market their services, and receive additional insurance reimbursement. Accredited centers also have lower direct patient care costs than nonaccredited centers because of insurance provider preference.

Surgical centers can seek accreditation through the American Osteopathic Association (AOA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), both of which accredit a broad spectrum of health care organizations. The Accreditation Association for Ambulatory Health Care (AAAHC), however, spe-

cializes in the accreditation of ambulatory surgery facilities and is the focus of this article.

ELIGIBILITY CRITERIA A facility seeking accreditation must meet the

AAAHC’s eligibility criteria. First, the facility must be licensed by the state and have delivered health care to patients for at least six months. Second, the health care provided by the facility needs to be man- aged by a physician or a group of physicians and be delivered in a nonjudgmental manner. Third, the facility must be run in accordance with the laws of the city and state government bodies. The facility’s size and the number and type of procedures performed are not factors in eligibility. Finally, submis- sion of a signed application, a presurvey questionnaire that provides the AAAHC with general information about the facility, and an application fee complete the criteria for eligibility.’

THE ACCREDITATION PROCESS Accreditation is awarded through a multistep eval-

uation process that emphasizes consultation with the surgical center. The Accreditation Handbook for- Amhu- latory Health Care is published by the AAAHC to

A B S T R A C T Ambulatory surgery centers are flourishing in the United States.

Accreditation of these unique facilities by the Accreditation Association for Ambulatory Health Care reflects a commitment to quality, patient- centered care and to excellence in this specialty area. The accreditation process is complex and lengthy; the benefits, however, outweigh the disadvantages. By successfully completing the accreditation process, a facility demonstrates to the public, its patients, and other health care professionals that it provides exemplary ambulatory surgical care. Successfully accredited facilities also have competitive advantages ovel nonaccredited surgical centers. AORN J 70 (Nov 1999) 81 4-821.

guide facilities through each step. Application for accreditation

survey. A facility seeking accreditation initiates the accreditation process by completing the application for accreditation survey, which assures the AAAHC that the facility meets the eligibility criteria and agrees to conform to the AAAHC’s policies and procedures. The signed application is submitted with a nonrefundable $395 application fee.

S U Z A N N E B R O W N , R N

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Self-assessment manual. The self-assessment manual provides the facility seeking accreditation with a tool that staff members can use to assess their center according to the same standards that the AAAHC will use during its on-site evaluation. The manual follows a checklist format and provides space at the end of each section for comments regarding areas of improvement.

The manual guides staff members in evaluating how well their facility conforms to the AAAHC's core standards of care and adjunct standards of care. The core standards of care are attributes that the AAAHC requires every surgical center to have before the facility can be accredited (Table I).'

The adjunct standards of care supplement the core standards and are specifically defined for each specialty service. Adjunct standards are established for anesthesia services, surgical services, overnight

care, occupational health, emergencyhrgent services, diagnostic imaging, pathologyflaboratory services, pharmaceutical services, and dental services.

On-site evaluation. When the facility seeking accreditation has completed the self-assessment manual, it contacts the AAAHC to schedule a survey date. On the selected date, the surveyors-a group of physicians, dentists, nurses, and/or administrators appointed by the AAAHC on the basis of their expe- rience and the type of facility being evaluated- arrive at the on-site location to gather information about how the facility fulfills the standards of care. They examine patient records, interview managers and other staff members, and observe daily activities at the facility.

When the on-site evaluation is concluded, the surveyors document their findings in a final survey report. They then meet with the managing body of the

Table 1 THE ACCREDITATION ASSOCIATION FOR AMBUIATORY HEALTH CARES CORE STANDARDS OF CARE'

Rights of patients

Every patient is treated with dignity, and their rights as a patient and human are respected. Governance

Managers establish and regulate policies and procedures for the facility. Administration

The organization is run in an efficient manner and guarantees the highest quality of health care in compliance with the facility's goals and mission statement. Quality of care The institution provides the best health care possible while maintaining a high level of professionalism and an ethical practice. This standard includes the use of cost-effective patient care procedures and treatments. Qualitv management and improvement Aspiring toward quality care and proficient use of the facilily and resources, the organization perseveres to create an "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.' Clinical records Patient records should be organized, legible, accurate, and available to authorized health care professionals. Professional improvement The facility aspires to increase the knowledge base and competence of both their medical and nonmedical employees to improve the quality of care provided. Facilities and environment The facility must maintain a clean, safe environment for patients and staff members

NOTE

111: Accreditation Association for Ambulatory Health Care, 1996/1997). 1 . Accreditation Association for Ambulatory Health Care, Accreditation Handbook for Arnbu/utory Healft, Cure (Skokie,

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ambulatory center to confer their findings. They also present recommendations and answer questions.

Accreditation decision. The AAAHC accreditation committee, which is composed of the AAAHC Board of Directors, reviews the survey report pre- pared by the surveyors, comments made by staff members during the on-site evaluation, and other per- tinent information that would aid in the decision- making process. The committee then finalizes its decision whether to accredit the facility. The facility subsequently is notified of the decision by mail.

Duration of accreditation. The accreditation committee will grant the facility an accreditation of three years’ duration if the facility successfully conforms with the established standards of care and if the committee believes that the facility will continue to provide quality care to patients. If the committee determines that the facility is abiding by the standards of care but has reservations regarding whether the facility will maintain these standards, the committee will grant a one-year accreditation and schedule an on-site evaluation at the end of the year.

To retain accreditation, a facility must seek reaccreditation every three years. The center must complete a reaccreditation application and another presurvey questionnaire as well as submit an application fee and schedule an on-site evaluation. The reaccreditation on-site survey by the AAAHC surveyors must occur within the two months before the accreditation expiration date. The AAAHC therefore rec- ommends that the application and questionnaire be submitted to the AAAHC within four months of the expiration date.

THE BENEFITS OF ACCREDITATION Accreditation of an ambulatory surgery center

may allow the facility to receive Medicare and/or third-party reimbursement for services performed on patients during their stay. Medicare determines which services are reimbursed and grants reimbursement to only those facilities that have successfully attained accreditation through Medicare certification or the AOA’s, JCAHO’s, or AAAHC’s deemed status survey accreditation program, in which on-site evaluations are unannounced rather than prescheduled.

Accreditation also allows the facility to charge a facility fee in addition to physicians’ fees, a benefit that provides the facility with more compensation to cover costs. The services and materials that may be incorporated into the facility fee include the use of the ambulatory surgery center, nursing care, administra-

Through ongoing self-

evaluation, the accredited

surgery center soars ahead of

nonaccredited centers.

tive services, anesthesia materials, on-site laboratory services, dressings, splints, and blood products. Physicians’ services, off-site laboratory services, ambulance services, and some orthopedic/prosthetic items cannot be included in the facility fee.‘

Continuous quality improvement (CQI) is another benefit of accreditation. Through ongoing self- evaluation, the accredited surgery center soars ahead of nonaccredited centers in its competitive advantage and quality of care. It displays to the public that the facility has met the AAAHC’s standards and is a knowledgeable organization that emphasizes excellence. By stressing the facility’s strengths and point- ing out areas in need of further improvement, data- based CQI allows the organization to look at itself in a more critical manner.

The AAAHC publishes and distributes a list of surgery centers accredited for one- and three-year terms. Health care professionals and the public can request this information by mail or telephone, or they can find it on the Internet. A displayed certificate of accreditation signals to the public, patients, and other health care professionals that the surgery center’s hard work has been recognized. It also attests to the high goals the facility has set for providing quality care to its patients. A facility that continues to be successful in maintaining the standards of care highlights the achievements of the organization and demonstrates a genuineness in delivering quality health care to the surrounding communities. Over time, the com- munity will be drawn to the center, use its resources, and contribute to its growth.

THE DISADVANTAGES OF ACCREDITATION The cost of improving a facility to meet the

AAAHC’s standards of care may be a barrier to accreditation for some organizations. A center may

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After it is awarded

accreditation, the facility

must be dedicated to main-

taining the standards of care.

have to make changes in the physical layout of its facilities for it to function in a safe, efficient manner. Environmental changes may include modifying doors, walls, and emergency exits as well as improving access to sterile supply rooms and equipment. Also, the mix of staff members must be evaluated to ensure that the facility’s needs are being met in terms of the complexity of the procedures being performed. The facility may have to hire additional professionals to adequately and safely staff the accredited facility. Other costs the facility will incur during the accreditation process include the application fee ($393, fees for the self-assessment manual ($50), the on-site survey (approximately $3,000), and the Accreditation Handbook for Ambulatory Health Care ($80).

Another potential disadvantage of accreditation is the diligence required to maintain the standards of care. After it is awarded accreditation, the facility must be dedicated to maintaining these standards not only for the accreditation committee but also for the staff members and, ultimately, for the patients.

Finally, the time spent working toward accom- plishing the standards of care may become lengthy and time consuming. For some facilities, it may take more than one year to meet the standards and to prop- erly complete the paperwork before the on-site evaluation can occur. The most time-consuming step of the accreditation process is the facility’s self-evaluation. The center may find that it exceeds the standards of care in some areas but needs to make large improvements in other areas.

The accreditation process can be a stressful peri- od of time for the facility. The benefits of accreditation, however, outweigh the potential costs. The facility personnel can overcome the stress by being precise in their self-evaluation, having adequate staff assis- tance, and exhibiting pride in their organization.

THE NURSE MANAGER‘S ROLE The nurse manager plays a significant role in

the accreditation process, beginning with the selec- tion of a decision-making model that reflects the facility’s mission statement. The nurse manager, along with the physicians and other managers, is in charge of upholding the facility’s current policies and both its nursing- and nonnursing-related procedures. The nurse manager also implements the new policies deemed necessary for accreditation of the surgery center. This responsibility includes maintaining the CQI and quality-assurance programs of the facility.

Employee involvement is crucial in all aspects of the accreditation process. As the facility grows, the nurse manager should hire qualified employees and delegate duties and projects associated with the accreditation process to proficient employees. Employee participation is limited to the scope of practice of each employee or department.

The accreditation process can be a strain not only on the managers of the facility but also on other staff members. The nurse manager must strive to create a positive work environment and keep his or her personnel motivated. These goals can be achieved by educating employees about the accreditation process and keeping them informed of the facility’s progress.

FAMILYMED FAMILYMED is an independently owned

physicians’ clinic and ambulatory surgery center in Omaha, currently seeking ambulatory surgical accreditation. The facility, approximately 7,000 sq ft in size, performs 1,600 to 1,800 procedures annually, including dermatologic procedures, diagnostic endo- scopies, vasectomies, and gynecologic procedures. The organization has enjoyed a growing patient pop- ulation and expansion of its diagnostic and therapeu- tic services. This growth has necessitated the hiring of additional RNs and technical personnel to staff the surgical component of the facility.

FAMILYMED’s physicians have served as the driving force behind the accreditation process. Strong leadership, good communication, and the desire to achieve excellence have contributed to a positive work environment and encouraged staff member involvement. Physicians have collaborated with the nurse manager to update and create new policies and procedures. The facility’s CQI team is physician-led, requiring participation of staff members at all levels. FAMILYMED’s CQI program

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includes a postoperative patient survey-an instru- ment that monitors patient satisfaction and outcome criteria on a quarterly basis-as well as laboratory machine calibration, staff member evaluations, and tracking of infection rates.

CONCLUSION Accreditation of an ambulatory surgery center

Suzanne Brown, RN, BSN. CCRN, is a staff nurse at FAMILYMED, Omaha. She also is a staff nurse in the critical care unit at Clarkson Hospital. Omaha.

requires dedication from both the management and The author Robert N, Brown, MD, other facility staff members. Accreditation grants the organization a competitive advantage over other facilities, and it demonstrates that the facility exem-

founder and Owner of FAMILyMED, Omaha, help in the preparation of this article,

his

plifies one of the highest levels of quality-driven care and reflects excellence in the field of ambulatory surgery. Above all, accreditation focuses on the most important customer-the patient. A

The Accreditation Association for Ambulatory Health care can be contacted by mail at 9933 ~~~l~~ Skokie, Il l 60077-3708; by telephone at (847) 676-9610; or by e-mail at [email protected].

NOTES

for Ambulatory Health Care, Accredited Organizations (Skokie, Ill: Accreditation Association for Ambulatory Health Care, April 1997).

2. Accreditation Association for Ambulatory Health Care, Accreditation Handbook for Amhulato? Health Care (Skokie, Ill: Accreditation Association for

1. Accreditation Association Ambulatory Health Care, 1996/1997)

3. Ibid. 4. Medicare Patients: Ambulatory

Surgical Centers. Available from www.medicarenhic.com/bene/asc .htm. Accessed 22 Sept 1999.

SUGGESTED READING Accreditation Association for

Ambulatory Health Care. “AAAHC marks loth year.” AAAHC News (May/June 1989) 23-25.

Accreditation Association for Ambulatory Health Care. Questions and Answers About Accreditation Survey Interviews. Skokie, Ill: Accreditation Association for Ambulatory Health Care, April 1988.

Cericola, S A. “‘Governance:’ A core standard for ambulatory surgery accreditation,” Plastic Surgical Nursing 16 (Summer 1996) 117- 118.

Most Physicians Resuscitate Low Birth Weight Infants Despite high odds that extremely low birth weight (ELBW) infants will not survive or, if they do, will grow up with severe long-term neurologic and devel- opmental impairments, 96% of delivery room physicians recently surveyed stated that they provide neonatal resuscitation to ELBW neonates. The fiid- ings, reported in a recent article in Image: Journal of Nursing Scholarship, were the result of a study sup- ported in part by a grant from the American Acade- my of Pediatrics Neonatal Resuscitation Program.

The 54 physicians interviewed in the study expressed high degrees of uncertainty and internal conflict over ELBW resuscitation. The main factors affecting their decisions were expectations surrounding their roles as physicians, a lack of rules and guidelines regarding resuscitation, and difficulties in making parents comprehend the serious health prob- lems that ELBW infants face as they grow. The sta- tistical probability of survival, legal constraints, and

the cost of continuing care did not appear to greatly affect their decisions. Half of the physicians indicat- ed that they would resuscitate ELBW infants regard- less of parental wishes. Only 4% said that it was appropriate to allow some ELBW infants to die, but 34% said they would not resuscitate an ELBW neonate of their own.

According to the article, more than 54,500 neonates weighing under 1,500 g are born each year in the United States. Resuscitation of neonates older than 27 weeks and weighing more than 750 g has been fairly successful. Babies born before 27 weeks’ gestation have a reported 40% rate of moderate to serious morbidity, with long hospitalizations, exten- sive treatments, and numerous surgeries.

A J Catlin, “Physicians‘ neonatal resuscitation of exlremely low-birlh-weight pretem infants, ” Image: Journal of Nursing Scholarship 3 1 (Third Quan‘er 1999) 269-275.

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Accreditation of Ambulatory Surgery Centers

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