Understanding the Importance of Accreditation in Healthcare Settings

1. Accreditation Jill Humes, BSN, RN, Vascular Access Manager Renal Intervention Center, L.L.C.

2. Is Accreditation Required? • Each state sets specific requirements for licensure • Requirements regarding licensure & accreditation vary from state to state • Certification by Medicare required to serve Medicare beneficiaries

3. Examples of State Regulations(ASC & OBS) • Accepts accreditation reports in lieu of licensing inspection • Requires accreditation within 1-2 years of licensure • ASC not accredited are subject to annual licensure inspection survey

4. Open for 6 months or more 4 or fewer surgeons (physician, dentist, podiatrist) performing operative or invasive procedures. OBS practices, including multi-site practices, limited to 4 or fewer licensed independent practitioners No more than 4 physicians (surgeons) & no more than 2 operating or procedure rooms in a single practice location Surgeon owned or operated, e.g. professional services corporation, private physician office, or small group practice Invasive procedures provided to patients Local anesthesia, minimal sedation, conscious sedation, or general anesthesia is administered OB practices that render 4 or more patients incapable of self-preservation at the same time are required to meet the provisions of the Life-Safety Code Eligibility Requirements Specific to Office Based Surgery Accreditation

5. What Does Accreditation Provide? • Symbol of quality and safety given by an outside organization • In some cases, ability to bill & receive payments • Possible opportunity to negotiate lower liability insurance rates • Announces adherence to state laws • Strengthens place in marketplace & among consumers • Lower direct patient care costs than nonaccredited centers due to insurance provider preference • Ability to compare performance to other ASC through external benchmarking requirements of all accrediting agencies • Opportunity to network with other accredited organizations

6. Two Step Process • Application • Site review, or survey

7. Standards • Governance or Leadership • Patient Rights & Responsibilities • Personnel • Environment • Provision of Care • Safety • Infection Prevention & Control • Medical Records • Quality Assurance and Improvement

8. Governing body that assumes full legal responsibility for determining, implementing, and monitoring policies governing the facility’s total operation Develop, implement, maintain on-going data-driven quality assessment and improvement program On-going infection control program based on nationally recognized IC guidelines designed to prevent, control, and investigate infections and communicable diseases Disclose to the patient any physician financial interest or ownership in the ASC prior to the date of the patient’s procedure Additional Standards For Medicare Deemed Status

9. On-Site Review or Survey • 1 to 2 days on-site • Unannounced for Medicare Survey • Surveyors • Pre-survey meeting • Post-survey meeting

10. Surveyors Review • Committee meeting minutes • Polices and procedures • Personnel records and physician credentialing records • Medical records • Quality data • Infection prevention and control records • Adverse events including hospital transfers • Emergency event policies and drills • Equipment log, recall log, implant log, tissue pathology log, environmental tracking log, etc. • Pharmacy records • Contracts

11. Survey Includes • Inspection: Life Safety Code (If applicable) • Observe • All areas, clinical & non-clinical • Staff compliance with policy and procedure • Procedures • Interview • Management • Staff • Patients/family members

12. Accrediting Agencies • Three Major Accreditation Agencies • Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), www.aaahc.org • The Joint Commission, www.jointcommission.org • American Association for Accreditation of Ambulatory Surgery Facilities, Inc. www.aaaasf.org

13. CMS Requirements for Agencies • Apply for approval of deeming authority • Provide CMS with reasonable assurance that the accreditation organization requires the accredited provider entities to meet the requirements that are at least as stringent as the Medicare conditions through survey activities & application review process • Once approved, reapply for continued approval of deeming authority every 6 years or sooner as determined by CMS

14. Non-Medicare Deemed Fee determined by size, type, & range of services provided by the organization Range $2,200.00 to $7,000.00, on-site survey fees plus annual fees Medicare Deemed Fee determined by size, type, and range of services provided by the organization Range $3,100.00 to $11,225.00, on-site survey fees plus annual fees Fees for Accreditation

15. Helpful Tips With Accreditation • Research agencies to determine which fits best the facility goals & environment • Create an Accreditation Team • Include management & physicians • Research • Oversee accreditation process • Create processes for internal audits & benchmarking

16. Appoint a trustworthy person to maintain and manage the accreditation process • Prepare a timeline • Purchase accrediting agency handbooks and self-assessment guides • Attend training programs/workshops

17. Develop/review policies Governance Administration Infection Control Risk Management Medical Records Compliance HIPAA OSHA Personnel Anesthesia Services Quality Assurance Quality Improvement Patient Rights Sterilization Fire Safety

18. On-going staff training & education • Conduct self-assessment, mock surveys, audits • Consultants are available (fee) • Organize, Organize, Organize! (examples) • Records • Logs • Contracts • Inspections • Drills • Preventative & corrective maintenance

19. #1 Tip • Do Not Procrastinate! • Survey application process is time-consuming • Keep up with on-going issues and new regulatory requirements • Keep records/logs/policies current • Continuous on-going quality assurance and improvement

20. What Happens After The Survey • Deficiencies & Corrective Actions • Accreditation Decision • Celebration…