Accreditation Office based Surgery accreditation Involves - PDF document

ASDIN 7th Annual Scientific Meeting Why? � Ambulatory Surgery Centers accreditation Accreditation � Office based Surgery accreditation � Involves review of procedures, medical staff, and physical environment � Time consuming � Resources needed Why, Who, How? � Expensive Jill Humes, BSN, RN, Vascular Access Manager Renal Intervention Center, L.L.C. Benefits of Being Accredited � Symbol of Quality � Patient Safety � Reduced risk exposure � Third party payers, medical organizations, liability insurance companies, state & liability insurance companies, state & federal agencies � Reduced losses from patient claims � Staff � Patients � Potential opportunity to negotiate lower liability insurance rates � Quality Improvement Who? � Education � Three Major Accreditation Agencies � Accreditation Association for Ambulatory Health Care, � Surveyors Inc. (AAAHC), www.aaahc.org � Staff � The Joint Commission, www.jointcommission.org � American Association for Accreditation of Ambulatory Surgery Facilities, Inc., www.aaaasf.org 1

ASDIN 7th Annual Scientific Meeting CMS Requirements for Agencies Fees � Apply for approval of deeming authority � Non-Medicare Deemed � Medicare Deemed � Provide CMS with reasonable assurance that the � Fee determined by � Fee determined by size, type, and range size, type, and range accreditation organization requires the accredited of services provided by of services provided by of services provided by of services provided by provider entities to meet requirements that are at provider entities to meet requirements that are at the organization the organization least as stringent as the Medicare conditions through survey activities and application review process � Range $2200.00 to � Range $3100.00 to $6950.00, on-site $11,225.00, on-site � Once approved, reapply for continued approval of survey fees plus survey fees plus deeming authority every 6 years or sooner as annual fees annual fees determined by CMS Eligibility Requirements Specific to The Survey Process OBS Accreditation � Open for 6 months or more � Invasive procedures provided to � Create an Accreditation Team including management and physicians to patients research, oversee the accreditation process, and create processes to do internal audits and benchmarking � 4 or fewer surgeons (physician, dentist, podiatrist) performing � Local anesthesia, minimal sedation, operative or invasive procedures. conscious sedation, or general Research: which agency best fits the facility’s goals and environment � OBS practices, including multi-site anesthesia is administered practices, limited to 4 or fewer � Set of Standards for OBS and ASC licensed independent practitioners � OB practices that render 4 or more patients incapable of self- ti t i bl f lf � Patient Rights and Responsibilities � No more than 4 physicians preservation at the same time are � Governance or Leadership (surgeons) and no more than 2 required to meet the provisions of operating or procedure rooms, in a the Life-Safety Code � Personnel single practice location � Environment � Provision of Care � Surgeon owned or operated, e.g. � Safety professional services corporation, � Infection Prevention and Control private physician office, or small � Medical Records group practice � Quality Assessment and Improvement In addition to the accrediting agency standards, Medicare standards also apply for Medicare Deemed status: � A governing body that � On-going infection control � Education and Resources assumes full legal program based on nationally responsibility for recognized IC guidelines determining, designed to prevent, control, � Accrediting agency handbooks and self- implementing, and and investigate infections assessment guides monitoring policies g p and communicable diseases governing the facility’s total operation � Disclose to the patient any � Training programs and workshops physician financial interest or � Develop, implement, ownership in the ASC prior maintain on-going, data- to the date of the patient’s � Preparation Timeline driven quality procedure assessment and improvement program 2

ASDIN 7th Annual Scientific Meeting � Submit application � Self-assessment � Review standards � Prepare! � Determine what needs to be in place to meet the standards of the accrediting agency � Organize O i � Review and record policies and processes � Educate and train staff � Review/audit � Meet the requirements of the accrediting � Implement agency for application � Mock survey On-Site Survey � Pre-survey meeting � 1 to 2 days on-site � Review � Committee meeting minutes � Policies and procedures � Unannounced for Medicare Survey � Personnel records and physician credentialing � Medical records � Medical records � Quality data � Surveyors � Infection prevention and control records � Adverse events including hospital transfers � Emergency event policies and drills � Equipment log, recall log � Pharmacy records � Contracts � Deficiencies and corrective actions � Inspection: Life Safety Code (if applicable) � Observation � All areas, clinical and non-clinical � Accreditation decision � Staff compliance with policies and procedures � Procedures � Interviews Celebration! � Management � Staff � Patients/family members � Post survey meeting 3