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Get three tips, insight into an AAAHC survey

Ambulatory Safety Monitor, April 28, 2004

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When staff at the Delaware Eye Surgery Center in Rehoboth Beach, DE, experienced their first accreditation survey, they were surprised the AAAHC surveyor didn't run down a checklist of issues, says Robert Uffelman, the center's risk management director. Instead, the surveyor focused on how leaders make decisions and communicate those decisions to staff.

Check out three areas of interest to the AAAHC surveyor:

1. Leaders and decisions
The surveyor questioned leaders about the following:
*  How the center carries out new policies
*  How it informs staff about new policies and procedures
*  How leaders define a medical incident

A "medical incident" refers to a breakdown in the internal process at Delaware Eye Surgery Center. When asked how its staff respond to an incident such as wrong-site surgery, leaders shared this response: A surgical practitioner notifies the risk management department and the risk director, and the director contacts the center's owners and works with the head nurse to identify how the problem happened and how to correct it. The surveyor found this process acceptable, says Uffelman.

2. Credentialing
After reviewing the credential files, the surveyor recommended the following:
*  Staff should make the privileging process more specific. Staff then changed the forms to reflect the different levels of anesthesia the anesthesiologists are qualified to administer, says Uffelman.
*  Anesthesiologists need to accurately record what they discussed during a presurgery exam with a patient.

3. Quality improvement
A state inspector visited the facility when it first opened in March 2003 and told staff to focus on infection control when conducting quality improvement (QI) studies, says Uffelman. However, there are other QI topics beyond the state requirements that will help the facility improve patient care, the AAAHC surveyor told Uffelman.

The surveyor suggested using QI studies for other areas, such as the cost effectiveness of certain procedures. The surveyor also suggested monitoring patient satisfaction and physician satisfaction, Uffelman reports.

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