AAAHC Presentation

IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

© 2009 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.

AAAHC Accreditation for Ambulatory Surgery

Centers

Michon VillanuevaAssistant Director, Accreditation Services

Texas Ambulatory Surgery Center Society Annual Conference

Dallas, TX – November 13, 2009

Standards


About AAAHC

Over 4,500 currently accredited organizations

More than 330 trained surveyors, many are physicians, from all types of health care organizations

AAAHC Board expertise, committees & task forces examine every issue related to ambulatory accreditation and every new trend impacting on accreditation or quality of care.

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AAAHC Accreditation

Largest accreditor of ASCs 2662 - Total 950 - Medicare deemed status 157 – accredited ASCs in Texas 65 – deemed ASCs in Texas

Recognized by state agencies AZ, CA, CO, CT, DE, DC, FL, GA, IN, KS,

KY, LA, MA, MT, NE, NV, NH, NJ, NM, NY, NC, OH, OR, PA, RI, TN, TX, UT, VA, WA, WY

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AAAHC Standards for 2010

Please visit the AAAHC website for further detailsChanges in all core chapters, including new Chapter 7Changes to the many adjunct chapters including:

Anesthesia Services Surgical Services Diagnostic and Other Imaging Services

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AAAHC Standards

Core Chapters1. Rights of Patients2. Governance3. Administration4. Quality of Care Provided5. Quality Management and Improvement6. Clinical Records and Health Information7. Infection Control and Prevention and Safety (2010)8. Facilities and Environment

Adjunct Chapters9. Anesthesia Services10. Surgical and Related ServicesOthers, as appropriate

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News

11/10/09 – HHS Secretary Kathleen Sebelius announced that now 43 state survey agencies will be surveying 1300 non-deemed ASCs in an effort to prevent health care associated infections.

7/27/09 – HHS Secretary Kathleen Sebelius announces the oversight of the HIPAA Security Rule has been delegated to the Office of Civil Rights

7/1/09 - California became the 15th state to opt-out of physician supervision of CRNAs (416.42(c)(1))

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New CMS Conditions for Coverage (CfC)

Electronic Code of Federal Regulations, Title 42, Public Health, Part 416 ASCs, Subpart C – Specific Conditions for Coverage of the Code of Federal Regulations

http://ecfr.gpoaccess.gov/cgi/t/text/text-dx?c=ecfr&tpl=%2Findex.tpl

CMS Published the State Operations Manual (SOM) Revised Appendix L, Ambulatory Surgical Centers (ASC) – May 15, 2009

http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdf

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New ASC Survey Protocol

Task 1 Off-Site Survey Preparation Task 2 Entrance Activities Task 3 Information

Gathering/Investigation Task 4 Preliminary Decision-Making

and Analysis of Findings Task 5 Exit Conference Task 6 Post-Survey Activities

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Case Observation

At least one procedure to be selected Case selected should be one that is

not expected to exceed 90 minutes Surveyor will follow patient from pre-

op to recovery/discharge

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Case observation

Compliance with the following will be assessed:infection controlphysical environmentmedication administration, assessment of anesthesia and procedure risk pre-operative update assessment of changes from the H&Pprovision of surgical and anesthesia services post-surgical assessmentrecovery from surgery and anesthesiadischarge orders

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Infection Control Worksheet

CMS developed with CDC Effective October 1, 2009 Used by state agencies and Accrediting

Organizations (AOs) One surveyor must complete – includes

input from survey team Documentation of direct observation and

interviews Specifically requires interviews with staff

responsible for a particular function

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Revised ASC Conditions for Coverage effective May 18, 2009:

Expanded Interpretive guidelines Revisions made to the requirements

for many existing Conditions Three new conditions:

416.50 Patient Rights 416.51 Infection Control 416.52 Patient Admission, Assessment

and Discharge

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416.2 ASC Definition

REVISEDAmbulatory surgical center or ASC means:• distinct entity• physical separation by at least a 1-hour separation • only surgical* services not requiring hospitalization• has agreement with CMS as an ASC meet 42 CFR 416•surgical procedures not expected to exceed 24 hrs•time documented in clinical record:

• Admission • discharge order signed by MD/ Pt exits recovery room

•exceptional cases documented clearly

{*Definition of surgery adopted from American College of Surgeons (www.facs.org/fellow_info/statement/st-11.html)}

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416.41 Condition: Governing body and management AAAHC Surveyors will review GB

minutes: frequency of meetings and agenda items Evidence of monitoring, oversight and

accountability Review of delegated responsibilities Compliance with policies, including

written disaster preparedness QAPI

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416.42 Condition: Surgical Services

Review credentials files of Physicians: MD, DO, DDS, DMD, DPM, OD, DC

Licensed Criteria for privileging / specific list of

privileges granted Determine provision of surgical services in a safe manner:

Compliance with state and federal laws Compliance with acceptable standards of practice

AMA / ACOS / AORN / APIC Compliance with other CfC: 416.43-45, 416.51-2

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416.42 Standards:

(a) Anesthetic risk and evaluation

Policies and procedures and medical record review:

• Assessment for anesthesia risk prior to procedure

• Evaluation of patient for proper anesthesia recovery

(b) Administration of Anesthesia

• Anesthesiologist

• CRNA (physician supervision unless in opt-out state)

• Anesthesiology assistant (supervised by physician)

(c) State exemption – opt-out states

Iowa New Hampshire Washington

Nebraska New Mexico Alaska

Idaho Kansas Oregon

Minnesota North Dakota South Dakota

Wisconsin Montana California – 7/1/09

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416.43 Condition: Evaluation of Quality

Review for evidence that QAPI program:• Is proactive and ongoing• Is comprehensive and data driven – process and frequency of data collection and analysis•Evaluates systems, policies, practices, processes or events to identify problems that have occurred or may occur•Requires the determination of the root cause of problems•Results in effective actions to correct problems•Requires follow up to ensure performance improvement

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416.44 Condition: Environment

• Evaluation of compliance to ensure provision of surgical services in a safe and sanitary environment that is properly constructed, equipped and maintained.

• Evaluation of Life Safety Code compliance

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(c) Emergency equipment

• Ensure compliance with required emergency equipment

• Use of cricoidotomy set in place of tracheostomy set

• AED may be used if ASC determines appropriateness for types of patients served

(d ) Emergency personnel

• Review personnel files

• Training and competence to use emergency equipment and supplies

• CPR training

• Staffing to ensure such personnel are present when there is a patient in the ASC

416.44 Standards:

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416.45 Condition: Medical Staff

Medical staff responsibilities are outlined and they are held accountable to the governing body

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416.45 Standards:

(a) Membership and clinical privileges

Policies and procedures and credentials and personnel record review: State licensure, certifications Relevant training and experience Recommendations by qualified medical personnel Specific list of privileges granted

(b) ReappraisalsReappointment, including peer review

(c) Other practitionersLicensed practitioners (non-MD or RN)QualificationsSupervisionEvaluation of performance

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416.46 Condition: Nursing Service

Nursing services must be under direction of an RN.

Review:

• Qualifications

• Responsibilities

• Staffing

(a)Organization and staffing

• Clear, written responsibilities (job description)

• Nursing services consistent with “recognized standards of practice” (State laws and nationally recognized standards/guidelines, e.g., ANA, AORN)

• Verify RN with (ACLS) is on premises and sufficiently free from duties to respond rapidly to emergency situations

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416.47 Condition: Medical Records

Ensure ASC maintains complete, comprehensive, and accurate medical records; review policies and procedures and medical records:

(a)Organization• Interview with designated responsible for clinical records• Description of system• Collected and stored in a consistent manner• Timely access

(b)Form and Content of Record(1) Patient identification(2) Significant medical history and results of physical examination(3) Pre-op diagnostic studies (entered before surgery), if performed(4) Findings / techniques of operation including path report on all

tissues removed during surgery, except those exempted by GB(5) Any allergies and abnormal drug reactions(6) Entries related to anesthesia administration(7) Documentation of properly executed informed patient consent(8) Discharge diagnosis

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Interview with licensed healthcare professional designated responsible – evidence of active direction and oversight

(a) Administration of drugs Policies and procedures regarding medication dispensing and

administration and use of biologicals in accordance with state and federal laws and nationally recognized standards, e.g., State Pharmacy Board, Institute of Safe Medication Practices

Staff responsibilities regarding prescription pad security, security of controlled and non-controlled substances, and drug recalls

Safe practices for the use of single use syringes and needles and multi-dose vials

Pharmaceutical logs/inventory/wastage, including samples Pharmacy consultant contract (if applicable)

416.48 Condition: Pharmaceutical Services

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416.49 Condition: Laboratory and radiologic services

AAAHC Surveyors will determine:

If ASC performs laboratory services:

•Must have current CLIA Certificate or CLIA Waiver

If ASC does not provide laboratory services:Must have procedures and well-defined contract for obtaining routine and emergency laboratory services from certified laboratory

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416.49 Standard: (b) Radiologic services

If ASC does not provide radiologic services and is integral to procedures performed:

•Must have procedures for obtaining radiological services from a Medicare approved facility

If ASC provides radiologic services:

•Meets hospital CoPs for radiologic services specified in §482.26 (Radiologic services)

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Questions:

AAAHC has four regional corps:

• East

• West

• Central

• Global

For questions about AAAHC accreditation or AAAHC/Medicare Deemed Status, ASCs in Texas please contact the AAAHC Central corps.

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Regional Corps for Texas

Regional Manager Dan Vincent (847) 853-6065

Application Coordinator Lenny Wojt (847) 324-7725

Scheduling Coordinator Leah Peters (847) 853-6061

Packets/Decisions Clerk Ana Olivares (847) 324-7739

Survey Process Secretary Maggie Schorr (847) 324-7735

Accreditation Process Assistant Melanie Tumang (847) 324-7732

Report Coordinators Amy WarmanDenisa Mateev

(847) 324-7737 (847) 324-7740

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Michon Villanueva(847) 853-6063 /

[email protected]

AAAHC “The Accreditation Association”

Phone: 847-853-6060Web site: www.aaahc.orgE-mail: [email protected]

Contact AAAHC

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