This installment of Retina in the ASC is part 2 in a two-part series on accreditation. In part 1, Barbara Ann Harmer, RN, BSN, MHA, defined accreditation, outlined the pros and cons of going through the process, and provided the most recent information regarding state requirements for accreditation of ambulatory surgical centers.

In part 2, Ms. Harmer describes the preparation required for accreditation, and the application and survey process. This two-part series is designed to help readers understand the commitment that is involved in becoming an accredited ambulatory surgery center. We welcome your comments and questions and provide our contact information at the end of the article.

-Pravin U. Dugel, MD

The achievement of accreditation in the United States was once optional. More recently, however, some states have opted for accreditation in lieu of licensure, third-party payers are requiring it before they will begin contract negotiations, and some specialty organizations require it of their member. The truth is that, in most cases, it is no longer voluntary but mandated. This article focuses on the steps that an organization should consider once it has made—or has had the decision made for it—to begin the preparation phase for an accreditation survey.

Choose and Get to Know An Accrediting Organization
Organizations that provide accreditation are numerous. It is important to ensure that where the ambulatory surgery center (ASC) is located has not limited the organizations for your consideration. For example, New York has designated three accrediting agencies that may be used to fulfill its requirement for organizations that opt to become accredited in lieu of licensure.

Once an accrediting organization has been selected, the handbook of standards should be purchased and reviewed. Become familiar with the mission, philosophy and process of the accrediting organization. The standards must be reviewed; do they match the ASC's own philosophy and goals? Are the standards designed to promote excellence, professionalism and patient and staff safety? Is the focus one that will ensure compliance with published standards through an educational and consultative approach?

It is also helpful to attend an educational workshop to learn more from the expert and to have the opportunity to hear directly from the surveyors on how to interpret the standards.

SELF-ASSESSMENT
The next step is to perform an assessment on how the ASC meets the standards set forth by the accrediting organization. It is important to determine whether the internal resources are available to complete the preparation phase or whether a consultant is required to guide the process. Resources will be expended either way during the preparatory period: Can day-to-day activities still continue and not suffer with attention redirected to getting ready? Are there internal staff members who have the knowledge base to interpret and apply the standards? Can anyone in the ASC effectively write policies and procedures?

If a consultant is employed, remember that the help received from this individual is limited to the preparatory period, and the ASC staff themselves must be able to convey to the surveyor/team that the standards are understood and can be applied. The consultant is a guide; all levels of the organization should be involved in the attainment and maintenance of accreditation.

With either approach, a point person should be assigned within the ASC. This individual should maintain control of the process by developing a timeline and then holding staff accountable for hitting their target dates. It is important to be realistic about how quickly the ASC can become ready; it takes approximately 10 months from the time the process is begun until a survey occurs. It is also crucial that the ASC allow for downtime, as there will be periods of time when preparation for the application process and subsequent survey will consume all that can be achieved in a workday; other examples would be vacation time, maternity leaves, holiday time, and staff departures from the organization.

The Application Process
After the self-assessment is complete, the application for the survey should be obtained. The information supplied for the application must be accurate and timely, and one must be careful not to focus too much on the narrative portions while neglecting applicable attachments. If the point person is given the responsibility for putting all the pieces together and answering the application questions, another individual in the organization should review all the documentation.

After the application is filed with all necessary fees, the next step is to wait for a phone call from the accrediting organization. For most types of procedural facilities, a surveyor will need to observe a procedure. This can have a bearing on what day or days of the week a survey may be scheduled. If the survey is announced (all but a deemed status survey), there is communication between the office and the organization on survey dates and availability. The ASC should have all key players present during the survey. Once there is a match with a surveyor/team, the survey is scheduled. A packet is sent confirming the date of the survey, the survey member(s), pertinent background, emergency information, and a detailed draft agenda. In most cases (not deemed status surveys), the leader of the survey team (known as the chair) will contact the ASC to discuss any outstanding questions or concerns.

If the accrediting organization has requested a deemed status survey (Centers for Medicare & Medicaid Services certification and Accreditation Association for Ambulatory Health Care Accreditation at the same survey time period), the home office confirms a completed application and then verifies at least a 90-day period that the organization may be surveyed. Deemed status surveys are unannounced, and, once that window of opportunity is set, an ASC can expect a visit at any time during that period.

THE SURVEY
It is by invitation from the ASC that the surveyor/team arrives. The scope of the survey is determined by the size and complexity of the ASC, which then determines the length of the survey and the number of surveyors. Of course, the pricing of the survey varies with the above considerations. The surveyor/team assesses such issues as governance, administration, policies and procedures, quality management and improvement, facilities and environment, infection control, safety, medical records, personnel and credentialing, and privileging files.

At the conclusion of the survey process, there is a summation meeting where all the standards that were applied to the organization are reviewed and discussed.

The accreditation decision is communicated to the ASC and, if a positive decision is announced, accreditation is granted.

SUMMARY
Accreditation of ASCs requires both a financial and staff resource investment; however, the benefit of receiving accreditation and the reward of being certified are an outstanding example of a health care practice that is worth the effort.

Barbara Ann Harmer, RN, BSN, MHA, has been an AAAHC surveyor for 22 years and is the Senior Consultant for Healthcare Consultants International, Inc. She can be reached at +1 800 982 6060; or via e-mail at HCIHELP@aol.com.

Pravin U. Dugel, MD, is Managing Partner of Retinal Consultants of Arizona and Founding Member of the Spectra Eye Institute in Sun City, AZ. He is a Retina Today Editorial Board Member. Dr. Dugel can be reached via e-mail at pdugel@gmail.com.