Transcript Accreditation Slide Show

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