Accreditation

Jill Humes, BSN, RN, Vascular Access Manager

Renal Intervention Center, L.L.C.

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

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

Eligibility Requirements Specific to Office Based Surgery Accreditation

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

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

Two Step Process

Application

Site review, or survey

Standards

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

Additional Standards For Medicare Deemed Status

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

On-Site Review or Survey

1 to 2 days on-site

Unannounced for Medicare Survey

SurveyorsPre-survey meetingPost-survey meeting

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

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

Accrediting Agencies

Three Major Accreditation AgenciesAccreditation Association for Ambulatory Health

Care, Inc. (AAAHC), www.aaahc.orgThe Joint Commission,

www.jointcommission.orgAmerican Association for Accreditation of

Ambulatory Surgery Facilities, Inc. www.aaaasf.org

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

Fees for Accreditation

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

Helpful Tips With Accreditation

Research agencies to determine which fits best the facility goals & environment

Create an Accreditation Team Include management & physiciansResearchOversee accreditation processCreate processes for internal audits &

benchmarking

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

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

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

#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

What Happens After The Survey

Deficiencies & Corrective Actions

Accreditation Decision

Celebration…