Issue link: https://beckershealthcare.uberflip.com/i/808731
42 QUALITY & ACCREDITATION The 6 Biggest Areas AAAHC Wants ASCs to Target in 2017 By Eric Oliver R aymond Grundman, the chief business development office with the Accreditation Association for Ambulatory Health Care, specified the six areas the accreditation association wants ASCs to focus on in 2017. 1. Credentialing, privileging and peer review. Credentialing, privi- leging and peer review are three separate but interrelated processes: • Credentialing validates a provider's qualifications to offer health- care services. • Privileging is the process of governing body approval for a pro- vider to deliver specific treatments, procedures or to use specific equipment. • Peer review is the process of confirming a provider's ongoing competence by enlisting similarly licensed others to review clin- ical records and other aspects of care, such as infection rates, compliance and patient satisfaction surveys. Surveyor comments associated with deficiencies for these processes include: • Peer review not being incorporated into the reappointment pro- cess; • Delineation of privileges for specific procedures or use of spe- cific equipment; • Appropriate primary or secondary source credentials verifica- tion were not performed. 2. Documentation. Requirements for documentation appear throughout the standards. Oen, an organization has a process to meet standards requirements, but the process's follow-up doesn't include written documentation when it should. Two specific areas frequently cited are allergy docu- mentation and written evaluation of scenario-based emergency drills. 3. Safe injection practices and medication safety. Multiple standards related to safe injection practices and medication safety had high lev- els of deficiencies last year. Proper storage and use of multi-dose vials and recall policies topped the list. 4. Staff education and training. An important part of maintain- ing and improving quality and safety is staff education and training. When new staff and providers join the organization, national guide- lines change, so staff and providers need sessions to remember/rein- force what they once knew. Training must be sufficiently frequent to ensure staff and providers are up-to-date. Surveyor findings regarding non-compliance included the failure of physicians to participate in infection prevention and safety training. 5. Quality improvement program. Part of being a high-performing and accreditable organization is showing a commitment to continu- ous improvement. A well-organized quality improvement program and documentation of effective quality improvement studies are key elements. e deficiencies here are strongly associated with the lack of or inad- equacy of a measureable, quantifiable performance goal. To ensure that the goals meet the requirements, they should be specific, mea- sureable, achievable, relevant and time-bound. 6. Performance maintenance of standards with high compliance. e highest compliance findings (100 percent rated substantially com- pliant) indicate that AAAHC-accredited organizations: • Provide patients with the opportunity to participate in decisions involving their health • Engage healthcare professionals who consistently practice their professions in an ethical and legal manner • Provide information to patients regarding fees for services and payment policies • Have implemented fiscal controls for rates and charges • Achieve consistency in documentation regarding the person re- sponsible for the patient's care • For Medicare Deemed Status surveys, there was strong overall performance with regard to over 200 specific AAAHC/Medicare standards. n 5 Conditions That Most Often Lead to Unplanned Readmissions: Sepsis Ranks as No. 1 By Mary Rechtoris U niversity of Pittsburgh Medical Center assessed the conditions that accounted for the highest number of unplanned hospital readmissions within 30 days, with sepsis leading the pack, according to MedPage Today. Researchers analyzed 1,187,697 hospitalizations linked to unplanned readmissions within 30 days to reach their conclusions regarding the following five conditions that led to the highest number of unplanned readmissions. • Sepsis: 12.2 percent • Heart failure: 6.7 percent • Pneumonia: 5 percent • Chronic obstructive pulmonary disease: 4.8 percent • Acute myocardial infarction: 1.3 percent "For physicians and patients, I think the most important implication of this study is that sepsis is an acute illness with long-term consequences," Sachin Yende, MD, of the University of Pittsburgh and study co-author, told MedPage Today. "Most people think that once you get better from sepsis and are discharged from the hospital, you don't have to worry about any consequences. What this study shows is that many of the patients are likely to come back into the hospital within 30 days." n