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AAAHC Accreditation 4-1-1 IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION Presenter Mary Wei • Assistant Director, Accreditation Services • AAAHC liaison to CMS • Staff liaison for Accreditation Committee Standards Presenter Benjamin Snyder, FACMPE, MPA • Surveyor since 1979 • Over 35 years of experience in health care management and operation in California Standards Today’s Objectives • Help you avoid common mistakes in the application and survey scheduling processes – mistakes that delay and complicate your survey experience • Review the Standards most frequently cited as out of compliance • Identify the requirements of those Standards and resources to assist you in achieving compliance Standards Thank you for choosing AAAHC! Standards Common Mistake # 1. Using the incorrect version of the Accreditation Handbook The Accreditation Handbook is updated every year. Surveys scheduled before March 1 and performed before June 30 will use the Handbook from the previous year. Surveys scheduled after March 1 and/or performed after June 30 will use Standards the Handbook from the current year. Common Mistake # 2. Untimely or late submission of the application. The application is electronic and found at www.AAAHC.org. Applications for re-accreditation can be submitted as early as 6 months prior to your current expiration date. Plan to have your completed application submitted at least 2 months prior to your current expiration date, but the earlier Standards the better. Common Mistake # 3. Changing the survey date after the survey is scheduled. Once the survey has been scheduled, a written confirmation is sent to the organization. Changing the survey date after this confirmation may result in additional fees and possible delays in performing the survey. Standards Common Mistake # 4. Lack of adequate preparation. Avoid These Common Mistakes: 1. Failure to read the Handbook and determine which chapters will be applied 2. Failure to use the Handbook worksheets as self-assessment tools 3. Failure to conduct a mock survey Standards 4. Failure to work as a team - accreditation is granted to an organization – this cannot be accomplished by one person Common Mistake # 5. Incorrect contact person listed. During the application or re-application process and throughout the term of your organization’s accreditation, AAAHC will communicate with the individual listed as your contact person on the survey application. Staff turnover and reassignment of duties in the accredited organization often results in this information becoming out-dated and inaccurate. Keeping Standards your customer profile current and up-to-date will ensure you continue to receive important information from AAAHC. Common Mistakes # 6. Lack of appropriate orientation for the survey team. Think about the unique attributes of your organization, and how you will communicate these with your survey team. Location, population served, local health risks Center expertise/what you’re known for, special services or procedures, unique facilities or Standards equipment Specialized staff training & experience Survey Team Orientation Meet and Greet An orientation should include having the survey team meet the organization’s staff in their immediate work area. In a smaller organization, it can be good for them to meet all employees, as small businesses often require close interaction among all workers. Effective ways of making surveyors feel welcome include greeting them immediately upon arrival, having a work area set aside for them to work with adequate privacy and electrical outlets for laptops, having the policy & procedure manuals pulled to this area and providing options for surveyors’ lunch. Standards Survey Team Orientation Acclimation An orientation also should include an acclimation process to help the survey team become familiar with the organization’s environment, facility and even the surrounding area. This should include a tour of the facility as well as information about items such as parking and nearby restaurants. The survey team should receive an overview of the organization's mission and operating structure, including how the center fits into the rest of a larger organization (if applicable). Standards Survey Team Orientation Fewer Mistakes, Faster Productivity The orientation benefits both the survey team and the organization. The surveyors benefit by getting off to a good start; having a clear idea of who can provide information, having many of the factual items needed for their report directly available. When the organization helps the survey team to be more productive and accurate in their data collection, the benefit is a better, more complete and accurate survey report that appropriately reflects the hard work the staff have put into preparing for the site visit. Standards Survey Team Orientation Rules of Engagement Many cultural norms are subtle and unstated. The greatest mutual benefit of the orientation is the opportunity to develop a shared language. The organization acclimates the surveyors to its unique environment and culture. The survey team introduces the “language of accreditation.” New employees or those new to the accreditation survey process may especially welcome the chance to meet and interact with the survey team who can then better serve as coaches and mentors during the survey process. Standards Top AAAHC standards marked less than SC Standards 2014 Standard 2. sub-I. B.12(f) Compliance with CMS requirements if the organization participates in the Medicare/Medicaid program. Avoid These Common Mistakes: 1. Not keeping the Governing Body well informed of CMS requirements 2. Any AAAHC Standard that has a crossreference to a CMS standard and is found Standards deficient, will be noted at this (CMS) standard. 2014 Standard 2. sub-II.D Privileges to carry out specified procedures are granted by the organization to the health care professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. Avoid These Common Mistakes: 1. Missing privileges for administration of anesthesia and/or supervision of others who administer anesthesia. 2. Missing privileges for specific technologies, procedures or activities, such as lasers, ultrasound, admitting patient to overnight care, operating a c-arm, interpretation of diagnostic images, ultrasound use for blocks. 3. Core privileges without a list of what is included in the Core. 4. Failure to re-privilege along with re-appointment. Standards 2014 Standard 2.sub-III.G The results of peer review activities are reported to the governing body Avoid These Common Mistakes: 1. Missing documentation in the minutes of the report of peer review activities to the GB. 2. Failure to connect the report of the peer review activities to its use in awarding Standards privileges. 2014 Standard 5.I.C.2 Identification of the measurable performance goal against which the organization will compare its current performance in the (quality improvement) study. Avoid These Common Mistakes: 1. No performance goal is stated 2. Performance goal is not measureable or quantifiable (i.e., We want to do “better”) 3. Performance goal is not related to the problem (i.e., Problem is ‘No Shows’, but Goal is ‘Reducing Waiting Time’ 4. Excessive reliance on ‘0%’ and/or ‘100%’ for performance goal 5. Performance goals that are not realistic or constructive (i.e., lacking evidence as from internal or external benchmarking) Standards 2014 Standard 5.1.C.6 A comparison of the organization’s current performance in the area of study against the previously identified performance goal. Avoid These Common Mistakes: 1. Failure to establish a measureable performance goal (5.I.C.2) will result in an inability to compare current performance. 2. Using the performance data from another facility (instead of your own data) to compare with your facility goal. 3. Using performance data that is unrelated to the original performance goal (i.e., Goal: “5% or fewer No Shows,” Current Performance: “80% of available appointment time is being used”). Standards 2014 Standard 6.F The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistently defined location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified. Avoid These Common Mistakes: 1. Record of the presence or absence of allergies is missing. 2. Documentation is not in a prominent/consistent location in the record. 3. Documentation is not recorded/updated at each visit. 4. Reliance on orange stickers on chart jacket that are not dated. 5. Policy and procedures do not identify for whom or when this recording is exempted, such as for physical therapy visits or counseling visits. 6. Over 50% related to untoward reactions not listed or inconsistently documented. Standards 2014 Standard 8.E The organization conducts at least one drill each calendar quarter of the internal emergency and disaster preparedness plan. One of the drills must be a documented CPR drill. The organization must complete a written evaluation of each drill and promptly implement any needed corrections or modification to this plan. Avoid These Common Mistakes: 1. Fewer than 4 drills performed and/or not performed according to calendar quarter (i.e., all drills performed during summer break). 2. No CPR drills (i.e., “since we don’t have a code cart”). 3. Inadequate or missing Internal Emergency & Disaster Preparedness Plan. 4. Drills do not include all staff and/or a written evaluation (i.e., parttime employees may need to be drilled individually). 5. Drill evaluations lack learning objectives or other basis for determining acceptable performance . Standards 2014 Standard 8.A.2 Application of state and local fire prevention regulations, such as NFPA 101 Life Safety Code Avoid These Common Mistakes: 1. Failure to meet all of the NFPA 101, 99, 110 LSC regulations on a CMS deemed or non-CMS deemed survey. 2. Failure to complete the Physical Environment Checklist (PEC) and use this as a self-assessment tool prior to the survey. 3. Not having periodic inspections from the local and/or State fire authority to help determine compliance. Standards 2014 Standard 9.T Malignant hyperthermia education, drills and written protocol, if applicable Avoid These Common Mistakes: 1. Failure to drill for a possible MH event. 2. Failure to post the MH protocol at each location where triggering agent used. 3. Inadequate supply of Dantrolene, per MHAUS Standards guidelines. 4. Missing written P&P on MH. 2014 Standard 10.sub-I.D Current health history must be completed within 30 days prior scheduled surgery/procedure Avoid these Common Mistakes: 1. H&Ps over 30 days on survey chart review 2. Failure to use Clinical Records Worksheet in Handbook as self-assessment tool 3. Using old H&P with “No Changes” when a CMS Standards deemed survey 2014 Standard 11.L If look-alike or sound-alike medications are present, the organization identifies and maintains a current list of these medications, and actions to prevent errors are present. Avoid These Common Mistakes: 1. Failure to identify look/sound alike medications. 2. Failure to maintain a list of look/sound alike medications. 3. Failure to mark medications with an appropriate warning system (i.e., warning label, TALL-man/shortman lettering). 4. Failure to have and/or use the most current Institute for Safe Medication Practice (ISMP) or similar list of look/sound alike medications as a reference. Standards 2014 Standard 12.I.D Policy to ensure test results are reviewed and documented by ordering physician or another privileged provider. Avoid These Common Mistakes: 1. Test results filed or scanned into medical record without signature or initials of ordering provider. 2. Missing P&P and/or Medical Staff Rules and Standards Regulations which identifies who, when, how test results may be signed or initialed by another. 2014 Standard 13.C.2 Privileges granted to health care professionals providing imaging and interpreting results. Avoid These Common Mistakes: 1. Privilege lists often state “C-arm privileges” without further explanation. Consider using the following: a) Privilege to operate the ___ portable fluoroscopyunit (identify the specific unit(s)) Standards & b) Privilege to interpret diagnostic images Summary : 10 Actions to Stay Survey-Ready 1. Stay current with most recent AAAHC Handbook, state regulations, CMS conditions. 2. Perform quarterly self-assessment audits of credentials, personnel, and medical record files. 3. Conduct a full mock survey annually. 4. Make accreditation readiness every staff member’s job (position description, Standards orientation, annual review). Summary : 10 Actions to Stay Survey-Ready 5. Keep meticulous records on Inspection, Testing, Maintenance (ITM) on all equipment and devices. 6. Document at least 2 QI studies each year and keep credentialing and peer review files current. 7. Document on-going surveillance of infection prevention/control practices including hand hygiene, instrument/equipment processing and staff education and training. OSHA focusing on Standards individual employee training on sharps injury prevention Summary : 10 Actions to Stay Survey-Ready 8. Focus on safe medication practices including medication reconciliation at each visit, look/sound alike meds, CDC guidelines for safe injection practices and use of multi-dose vials. 9. Use patient safety toolkits on surgical/procedural safety checklist, obstructive sleep apnea, falls prevention, VTE risk assessment. 10. Participate in continuing education programs Standards from CASA, ASCA and AAAHC, network with peers, ask for help when stumped. Achieving Accreditation Seminars CASC AEU’s are now available for participation in these programs. • December 5-6, 2014, M Resort, Las Vegas • March 21-22, 2015, Orlando • June 13-14, 2015, San Diego Standards Contact Us Mary Wei Office (847) 324-7745 Mobile (847) 668-5128 [email protected] Standards Questions? Standards