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A Kentucky multi-specialty center undergoes its first AAAHC survey

Ambulatory Safety Monitor, June 25, 2003

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Organized and uniform credential files helped the Cumberland Valley Surgical Center through its first AAAHC accreditation survey.

A peek into credentialing files: The surveyors made it clear that the AAAHC standards require the governing body to be responsible for all aspects of an organization. Thus, when they looked through the credentialing files, they wanted to see governing body minutes list all physician credentialing and privileging activities (see standard F7).

For example, list the names of the physicians to whom the governing body and medical director grants privileges in the meeting minutes, and the date of approval. "The surveyors told us that the governing body and medical director must have complete control over credentialing," says Kim Turner, Cumberland Valley Surgical Center's business manager. The center had not listed each physician that the governing body approved by name, but now they do, Turner says.

When physicians undergo the credentialing process, they must submit a privilege request to perform a certain procedure. Surveyors will look for that documentation, as well as the list of all procedures that the center provides.

The governing body must review and update the procedures list periodically. Surveyors looked for proof-via meeting minutes and an updated procedures list, "to see if perhaps we need to add new surgeries or if we should eliminate some riskier procedures," Turner says.

Credentialing requires consistency: Surveyors also zeroed in on ensuring current physician malpractice insurance and medical licenses. Turner gave the surveyors a physician roster and surveyors picked eight files to review.

TIP: Make everyone's life easier and use file folders divided into sections for each physician. Label each section with the appropriate information, such as "malpractice insurance," "application," "governing body approval," and so on. Keep files consistent, devoting section four in all of them to "application," for example. "At first, all of our credentialing files were in one manila folder," Turner says. "Now, we maintain each separate file in the same manner."

This week's tip was excerpted from Briefings on Ambulatory Accreditation, a monthly publication that reports on the activities of the ambulatory care accreditors, the JCAHO and the AAAHC. It illustrates exactly what you and your staff need to do to pass a survey and gain accreditation so that your organization is known for quality and can affiliate with other delivery systems. For more information, or to subscribe, click here.

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