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Early start helps ASC earn accreditation

Ambulatory Safety Monitor, December 9, 2004

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When Central Indiana Orthopedic Surgery Center of Anderson opened a little more than a year ago, administrators wanted to obtain accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC) as soon as possible. To achieve this, the surgery center prepared from the start by putting its policies and procedures in order and maintaining meeting minutes, says Michele Etchison, RN, director of the surgery center.

Under the surveyor's microscope

One surveyor from the AAAHC visited the orthopedic facility for two days. "He went through our handbook and addressed every item to prove we had policies for each area of service," Etchison says. Other points of interest included the quality improvement (QI) process, peer review, surgery oversight, and the credentialing process.

"The surveyor wanted to see that we're doing what we say we are doing," Etchison says. Although the surveyor thoroughly examined everything, the experience held no surprises and was beneficial. Because the facility had recently gone through state inspections-which she says weren't as pleasant as the AAAHC survey process-the center was well prepared.

Working toward a better process

Even though the facility's practices impressed the surveyor, he did offer suggestions for improvement. For example, the surveyor suggested the facility rotate who performs physician reviews for audits. At survey time, the medical director was in charge of the time-consuming task of performing all reviews. Because of the surveyor's recommendation, the center now has all doctors participate in reviews on a rotating basis. The medical director still signs off on all reviews, but he now has more time to concentrate on other issues, Etchison says. The surveyor also suggested wording changes to policies to help the documentation work better for the organization.

Communicate to maintain a top-notch facility

Central Indiana maintains survey success by staying current with industry changes. "We don't want to get lazy because we hold ourselves to a high standard and want to be the best surgery center we can be," Etchison says. Staying current means purchasing the latest version of the AAAHC handbook for updated information about the standards, she says.

The surgery center also relies on the feedback from patient surveys. The surveys indicate negative trends that could benefit from a better process. The center asks the following questions:

* What did you think of the center?

* Was your pain controlled?

* Did you feel like you were in good hands with the staff?

* How would you rate your overall care?

Central Indiana also uses regular incident reporting as a learning tool. Reports are filed on anything, including family safety and housekeeping concerns. Etchison says her staff, including the physicians, support these practices because it improves their services.

Keep your staff in the know by hosting medical advisory committee meetings, as Etchison's facility does. At these meetings, staff should address problems, new developments, changes in standards, and seek approvals and input on medical issues.

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