Issue link: https://beckershealthcare.uberflip.com/i/548475
52 Quality & Accreditation Here are seven tips: 1. Ensure physicians are credentialed appropriately. The number one accreditation issue for the past 10 years has been improper physician credentialing, according to Michael Kulczycki, executive director of the Ambula- tory Care Program at The Joint Commission. Mistakes are made either when credentialing a physician for the first time or when physicians are re-credentialed. "The steps for credentialing are not difficult or complicated," says Mr. Kulczycki. "However, cre- dentialing does include a number of steps. So the real challenge is finding someone who is very detail- and deadline-oriented to be in-charge of credentialing. This process sometimes proves even more challenging for ASCs as their medical staff roster may include 40 or 60 or 80 physicians, which is a lot to track over the years. So it is not surprising that ASCs have trouble with this." With adequate attention to detail as well as fol- lowing certain best practices, ASCs can ensure they are staying on top of credentialing. "Also, having a specific person be in charge of the files, paper or digital, is essential to keeping things organized," says Deb Yoder, Director of Clinical Services, Surgical Management Profes- sionals, Iowa City Ambulatory Surgical Center "A surveyor doesn't want to muddle through a lot of disorganized paper work, so having fold- ers/tabs organizing the information is impera- tive. Old data can be stored in a secure area for review if needed. A surveyor told me 'if I can't find it on the first go through, I assume it's not there and move on.' " As the site grows and new procedures or equip- ment is added, make sure that information is added to the providers' privileges and credentials, she notes. 2. Understand the gravity of the accredi- tation process. Sometimes, ASCs do not take the process seriously and are unprepared, notes Kathleen Bernicky, RN, the director of clinical operations at Regent Surgical Health. Make sure you know your state regulations as well as CMS and accrediting agencies' standards. "Having a complete and accurate set of policies will guide the center," she says. 3. Ask questions and gain information to maintain high-quality care. Read and review information from evidence-based na- tional organizations such as Association of periOperative Registered Nurses and The As- sociation for Professionals in Infection Control and Epidemiology, says Ms. Yoder. The accredi- tors will look to them for guidance and best practice patterns. "For example, performing a time-out in the man- ner laid out by the World Health Organization or AORN aids in best case practice patterns and en- sures that the staff are clear on side/site/implants/ antibiotics needed," says Ms. Yoder. 4. Establish a structured program for completing every aspect of the accredi- tation process. Ms. Bernicky suggests that the program include an ongoing monitoring of a number of areas, such as: • Quality Assurance/Performance Improvement • Credentialing • Infection Control • Medication Management • Patient Care • Staff and LIP education • Privacy and Security Organization is essential, says Ms. Yoder. Keep your minutes and information in a standard binder or location. Keeping it up-to-date after each meeting and project aids in long term time management. Use a template to document all data — easy to fill in and consistent. Additionally, pay special attention to Life Safety Code requirements. These are becom- ing more difficult to ascertain and maintain without additional help before a survey, says Ms. Yoder. "The facility manager needs to be very cogni- zant of the current building and how it relates to the new standards — especially the HVAC system, temperature and humidity monitor- ing, fire wall penetrations, generator load tests/remote shut off valves and documenta- tion," she adds. Another important aspect of accreditation is medication management. Managing high- alert or hazardous medications as well as look-alike or sound-alike medications, says Mr. Kulczycki. 5. Ensure involvement of the leadership team. Leadership starts with the governing 7 Tips for ASCs to Ace the Accreditation Puzzle By Anuja Vaidya Deb Yoder Michael Kulczycki Kathleen Bernicky