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 Surveyors Pre-survey meeting Post-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 Agencies Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), The Joint Commission, American Association for Accreditation of Ambulatory Surgery Facilities, Inc.

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, 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, 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 & physicians Research Oversee accreditation process Create 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…