This installment of Retina in the ASC is part 1 in a two-part series on accreditation. In this first article, Barbara Ann Harmer, RN, BSN, MHA, defines accreditation, outlines the pros and cons to going through the process, and provides the most recent information regarding state by state requirements for accreditation of ambulatory surgical centers. -Pravin U. Dugel, MD

More Americans are having outpatient surgical procedures. In fact, the number of outpatient surgery visits in the United States increased from 20.8 million visits in 1996 to 34.7 million visits in 2006. Futher, outpatient surgery visits accounted for approximately half of all surgery visits in 1996—in 2006, nearly two-thirds of all surgery visits were for outpatient procedures.

WHAT IS ACCREDITATION?
Accreditation is for organizations that provide diagnostic, surgical or medical care on an outpatient basis, where an overnight stay is not required. In many cases, accreditation remains a voluntary process through which an organization is able to measure the quality of its services and performance against nationally-recognized standards. The accreditation process involves self-assessment by the organization itself, as well as a thorough review by the surveyors from the accrediting organization.

When the Accreditation Association for Ambulatory Health Care (AAAHC) surveyor or survey team visits your facility, it is a comprehensive peer-based examination by a group of highly experienced professionals.

Their approach is discovery not inspection, consultative rather than prescriptive, and collaborative not dictatorial. The surveyors will review the standards that are applicable to your organization. In 2009, the AAAHC accreditation manual has seven core chapters and 19 adjunct chapters. Core chapters are applied to every organization undergoing an accreditation survey. The adjunct standards are applied to an organization only where they are applicable according to the scope and discipline of the practice.

The accreditation certificate is a symbol that an organization is committed to providing high-quality health care and that it has demonstrated its commitment by measuring up to the accrediting organization's standards.

ADVANTAGES/DISADVANTAGES
Accreditation is a public symbol of your commitment to high-quality health care; it gives your team a focus and common purpose to maintain quality care and patient safety and is an opportunity for them to learn and to grow professionally. In my opinion, accreditation helps raise a practice to the next level.

Conversely, it is true that a facility can provide excellent care without accreditation and there are associated costs. The standards are extensive and it will require considerable time to gather necessary documentation, track data that are required, and to prepare for the actual survey. So why bother?

Reasons why accreditation is a worthwhile investment include:

  • • to provide better quality care;
  • • to appeal to patients;
  • • to provide for public recognition;
  • • to be responsive to increasing consumer awareness;
  • • to participate in the Medicare program for facility fee reimbursement;
  • • to aid in the negotiation process for reimbursement contracts;
  • • to fulfill requirement of third party payers;
  • • to recruit staff;
  • • to access managed care marketplace;
  • • to assist with marketing;
  • • to meet many states' requirement for accreditation as part of their licensure process (regulatory compliance);
  • • to save money; some of the tips and procedures you learn from an accreditation survey can indentify other savings opportunities;
  • • to promote a positive organizational culture; staff must work together for these activities to be successful; and
  • • to assist with your staff's professional growth; skills learned in one aspect of an accreditation process can be carried over to other aspects of your business.

IS ACCREDITATION MANDATORY FOR ASCS?
Accreditation requirements are made on a state-bystate basis with a wide range of regulations. For example, beginning on July 14, 2009, all office-based surgery practices in New York State who use moderate sedation are required to either obtain or maintain full accredited status with a nationally-recognized accrediting agency.

Twenty-five states and the District of Columbia require or recognize accreditation of certain types of ambulatory surgical facilities:

  • • Arizona
  • • California
  • • Colorado
  • • Delaware
  • • Washington
  • • Florida
  • • Georgia
  • • Indiana
  • • Kansas
  • • Maryland
  • • Montana
  • • Nebraska
  • • Nevada
  • • New Hampshire
  • • New Jersey
  • • New Mexico
  • • New York
  • • North Carolina
  • • Ohio
  • • Oregon
  • • Pennsylvania
  • • South Carolina
  • • Texas
  • • Utah
  • • Virginia
  • • Wyoming

For office-based surgery procedures meeting various thresholds, the following states require accreditation:

  • • Connecticut
  • • Indiana
  • • New York
  • • Ohio
  • • Oregon
  • • Pennsylvania
  • • Rhode Island
  • • South Carolina

Kansas requires that practices meet the requirements of accreditation. California and Florida require state certification or accreditation.

Louisiana, North Carolina, and Texas exempt accredited settings from surgery/anesthesia regulations or guidelines.

States that have adopted office anesthesia or surgery regulations are:

  • • Alabama
  • • Illinois
  • • Mississippi
  • • New Jersey
  • • Tennessee
  • • Virginia

States that have adopted voluntary guidelines of policy statements are:

  • • Colorado
  • • Washington
  • • Kentucky
  • • Massachusetts
  • • North Carolina
  • • Oklahoma
  • • Washington State

The Washington State Medical Quality Assurance Commission has issued proposed regulations, which would require accreditation of practices using defined levels of anesthesia. Arizona prohibits treatment under general anesthesia in unlicensed physician offices. In addition, the Arizona Medical Board has issued regulations specifying further requirements for office based practices, but not accreditation.

Seven states recognize AAAHC accreditation for quality assurance review of HMOs:

  • • Florida
  • • Georgia
  • • Kansas
  • • Oklahoma
  • • Pennsylvania
  • • Nevada
  • • Texas

Wisconsin recognizes AAAHC accreditation for Medicaid managed care plans.

Regulatory requirements are dynamic, so it is recommended that organizations consult with their state to make sure that they understand the latest guidelines.

HOW LONG DOES ACCREDITATION LAST?
AAAHC, for example, awards an organization accreditation for 3 years when it concludes that the organization is in substantial compliance with the standards, and the accreditation committee has no reservations about the organization's commitment to continue providing high-quality care; or for 1 year when a portion of the standards that were applied to the organization are acceptable but other areas remain to be addressed. Organizations that have been in business for less than 6 months by the date of their survey are eligible for an early option survey. The decision for this type of survey may be either a 6-month decision or a maximum level of 1 year.

Organizations that are found to have too many standards that have been only partially addressed may receive a deferral decision. This means that the organization has not been successful in becoming accredited and another survey will be scheduled within 6 months of the original survey date.

An unannounced random survey can occur any time from nine months to thirty months from your survey date. If it is found that the organization has not been maintaining compliance with the standards, the accreditation certificate may be revoked and this can have serious consequences for the future of the organization. If accreditation is a requirement for the organization and the certificate is pulled, the affected services must be discontinued. It will be necessary for the organization to reapply for an accreditation survey.

If there is any significant change (operational, clinical, financial) to an accredited organization, it is the responsibility of the organization to notify AAAHC within 15 days. For example, if an organization adds a satellite or services have been interrupted for more than thirty days, a special survey may be scheduled. When in doubt, it is best to notify the AAAHC office and let them make the decision.

A FINAL WORD
Accreditation benefits facilities in ways even the most conscientious health care practitioner may never think about. Yes, it represents a financial investment. Yes, the preparation takes time away from your surgical and medical practice. The benefits, however, far outweigh the costs and the inconvenience. Achieving accreditation gives you peace of mind knowing that your patients are receiving high-quality care, that their safety is paramount, and that your organization is an outstanding example of the very best practices in health care. ■

Barbara Ann Harmer, RN, BSN, MHA has been an AAAHC surveyor for twenty-two 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.