All Posts By

Pinnacle III

Header image for AAAHC deemed status survey blog

Preparing for Your AAAHC Deemed Status Survey  

By | ASC Development, ASC Management, Leadership

Why Accreditation?

Undergoing a AAAHC “deemed” status survey, where compliance to both Accreditation Standards and CMS Conditions for Coverage (CfCs) are assessed, is demanding for an ASC. However, there are many reasons why this is beneficial. In general, accreditation may help with consumer confidence, providing a competitive edge for your center in your market. Some states require accreditation in order to maintain licensure, and many insurers and third parties require accreditation as a prerequisite to eligibility for insurance reimbursement and for participation in managed care plans or contract bidding. In addition, being accredited may reduce liability costs.

Deemed status provides these benefits plus it qualifies as a state agency review for Medicare certification for new and existing centers. In most cases, the state will not review an ASC that has been accredited through the Medicare or AAAHC deemed status survey, but it does not preclude the state from conducting validation or complaint inspections.  State licensure inspections are separate from Medicare surveys and are conducted according to state requirements.

Public Notice of AAAHC Deemed Status Survey

Prior to the start of the on-site survey, a packet of information about the upcoming, unannounced site visit is sent to the applicant ASC’s primary contact person.  The packet includes a general outline of the survey event, a listing of documents surveyors may request for review, a copy of the Notice of Accreditation Survey for posting, and other survey information.

It is important that the center post the Notice of Accreditation Survey for at least 30 days prior to AAAHC’s arrival for survey.  If not, the survey will still be conducted, but an accreditation decision cannot be rendered until the Notice has been posted for a period of 30 calendar days.

The Accreditation Process: The AAAHC Deemed Status Survey Team

Although an accreditation survey is, of necessity, evaluative, AAAHC emphasizes the educational and consultative benefits of accreditation. Thus, AAAHC uses health care professionals and administrators who are actively involved in ambulatory health care settings to conduct surveys. 

The Accreditation Process: Surveyor Conduct

Surveyors are representatives of AAAHC. Their priority when conducting surveys is to serve as ambassadors of AAAHC, by being objective fact finders, and educators when appropriate. It is AAAHC policy and practice that surveyors do not participate in surveys of organizations that may be in direct competition with the surveyor’s business interests, or that bear any significant beneficial interest to the surveyor or the surveyor’s immediate family. AAAHC policy also states that, while serving as representatives of AAAHC, surveyors may not solicit personal business or take part in any activities that appear to be in furtherance of their personal, entrepreneurial endeavors.

The Accreditation Process: The On-Site Survey

Each survey is tailored to the type, size, and range of services offered by the ASC seeking accreditation. The length of the on-site visit and the number of surveyors sent by AAAHC are based on a careful review of the information provided in the Application for Survey and supporting documents submitted by the ASC. Questions regarding the scope of a survey should be directed to the AAAHC office prior to the survey.

At the start of the survey, the survey team conducts an orientation conference for the organization. The members of the survey team will introduce themselves, review the survey format, confirm written documentation for which they anticipate a need, and ask the organization to identify the key personnel who will provide the information and access necessary to complete the survey. This is also a time for the organization to ask questions.

The Survey Process: Preparing for Surveyors

ASCs are notified in advance to have specific documents and other information available for surveyors during the on-site visit. This allows surveyors to gather and review information with minimal disruption to the daily activities of the ASC being surveyed. Surveyors may, however, ask to see additional documents or request additional information during the on-site survey.

ASCs are asked to make a work-space available for surveyor use. This private or semi-private area is used to review polices, conduct interviews, and hold survey team meetings to discuss findings.

The Survey Process: The Tour

Survey teams conduct their tours differently; however, most will conduct the tour within one to two hours of being on site. Generally, the tour will closely follow the patient flow throughout the building.

During the tour, the surveyors will be escorted to the areas of observation, including patient check-in. During this time, surveyors will observe posted signs and evidence of quality of care.

Information intake will be next. Limited questions are asked.  Surveyors may ask staff to clarify a process or a policy (i.e., ”How often do you check the refrigerator?” or “What kinds of snacks do you give to patients?”).

Watch for breaches in infection control during the times surveyors are observing staff.  Stethoscopes around the neck, missed opportunities for hand hygiene, multiple bags of IV fluid pre-spiked are some examples of infection control breaches.

Generally, surveyors will look into an operating room through the windows or doors. Remember to be firm on protocol at this point. The clinical surveyor will determine when to observe a procedure. The surveyor may ask for a daily schedule to review to facilitate selection of a case or the surveyor may want to spend time with staff for casual observation.

The surveyors will then be shown recovery, post-op/PACU, and discharge.  At this point, the surveyors will return to the designated survey work-space.

The Survey Process: After the Tour

After the tour is completed, the surveyors will most likely conduct a confidential discussion between themselves before they proceed with the remainder of the survey.  If conducting a Medicare survey, the clinical/administrative surveyor will break off from the life safety surveyor. If you have a maintenance employee or employ a building maintenance company, it is best to have them present to assist in providing information to the surveyors, who may have questions related to facility management and maintenance. The life-safety surveyor is generally at the facility for one day; therefore, all information gathering is performed in a brief period of time.

At the conclusion of the on-site survey, the surveyors hold a formal summation conference where they present their findings to representatives of the organization for discussion and clarification. Surveyors are fact finders for AAAHC; they do not render the final accreditation decision. No information regarding the organization’s compliance with the standards or the accreditation decision is provided during the summation conference. Members of the organization’s governing body, medical staff, and administration are encouraged to take this opportunity to comment on, or rebut, the findings, as well as to express their perceptions of the survey.

After the AAAHC Deemed Status Survey

Accreditation decisions are made by the AAAHC Accreditation Committee following a thorough review of the information gathered during the survey and documented in the surveyor’s report, any other applicable supporting documents, and recommendations of surveyors and staff. All documents reflecting the opinions or deliberations of any AAAHC surveyor, staff member, committee member, or its officers or directors constitute peer review materials and are not disclosed to the organization seeking accreditation and Medicare deemed status, or to any third party.

AAAHC expects substantial compliance with the applicable AAAHC Standards requirements. Accreditation is awarded to ASCs that demonstrate compliance with the AAAHC Standards and adherence to AAAHC accreditation policies.  

Compliance with each requirement is assessed through at least one of the following means:

  • Documented evidence.
  • Answers to detailed questions concerning implementation.
  • On-site observations and interviews by surveyors.

The ASC will receive a written, comprehensive copy of the findings after the on-site survey.

AAAHC works with a third-party calling center (customer satisfaction Survey Company) to conduct an evaluation of our survey process and our surveyors.  A representative from the calling center will phone the organization’s designated primary contact approximately one week after the survey to discuss the recent survey experience.  Obtaining this input by telephone provides the surveyed organization and AAAHC with a streamlined, efficient means of providing and receiving feedback about the survey process.  An organization’s feedback has no bearing on the accreditation decision. 

Approximately ten business days after the last day of survey, the ASC will receive a formal request and instructions for completing the required Plan of Correction if deficiencies have been cited. AAAHC will provide the ASC with directions and a timeline for submission for the required Plan of Correction.

The letter of accreditation is typically received approximately 30 days after the completion of the survey.


source: Accreditation Association for Ambulatory Health Care, 2019, www.aaahc.org.

additional resource: Preparing for an ASC Accreditation Survey, 2018, www.pinnacleiii.com/preparing-for-an-asc-accreditation-survey.

Jovanna Grissom, Regional Vice President of Operations

Running an Effective, Efficient ASC Daily Huddle

Running an Effective, Efficient ASC Daily Huddle

By | ASC Management, Leadership

In the fast-paced, team-oriented environment of an ambulatory surgery center, a regular group meeting, also known as an ASC daily huddle, can serve as one of the most important times in an ASC’s day. A daily huddle can help staff get on the same page concerning potential challenges for the upcoming surgical day. Discussing foreseeable issues provides an opportunity to address them and helps ensure safe and productive operations.

In structuring an ASC daily huddle, clinical leaders must be sure to focus on engaging and relevant discussions. Otherwise, if huddles aren’t structured and executed meaningfully, they can quickly lose their value. Staff may start coming to huddles unprepared and disinterested. After a short while, huddles may be viewed as more of a social gathering or an optional meeting. Many may logically determine an unproductive huddle is a huddle not worth holding.

Daily Huddle Best Practices

Here are a few tips to make each ASC daily huddle more effective and productive.

Keep huddles short. A brief daily huddle helps keep people focused and engaged. Staff should come prepared to discuss only the issues and concerns that matter to the upcoming surgical day. A huddle is not an opportunity for staff to ramble or discuss insignificant topics. More serious issues requiring significant time and attention are also not appropriate for a huddle – these should be addressed as soon as they arise.

Consider using a timer to measure how long participants speak and track the huddle’s total time. Use this information to keep the discussion moving along in an efficient manner. A good time limit for an ASC daily huddle is seven minutes or less.

Choose an appropriate time for the huddle, then stick with it. Some ASCs hold their huddles in the morning. Some in the afternoon. But what other ASCs do shouldn’t matter to you. The time to hold your daily huddle should be what’s best for your ASC. If you seem to experience many issues in the morning (e.g., poor workflow, coordination, communication), a meeting every morning to plan out that day may be worthwhile.

If you tend to experience issues with appropriate staffing and instrument availability, for example, consider a mid-afternoon meeting. This can provide the time necessary to resolve such issues before the next day begins.

Once you determine the time that’s best for your ASC, do not deviate from it. This will help establish a routine for your daily huddle and better ensure participating staff do not miss a huddle.

Establish a consistent location. Holding the huddle in the same location can also support consistent participation. Choose a central location to make it as easy as possible for participating staff to attend. The location should be a private area that won’t interfere with operations.

Consider asking staff where they would prefer to hold the ASC daily huddle. This will help secure buy-in and ownership of the huddle.

Limit the number of participants. To maintain focus and avoid distractions, every daily huddle should only involve essential individuals. This typically means a single person from each department – business office, pre-op, operating room (OR), central sterile services department (CSPD) and post-anesthesia care unit (PACU).

Every department should be represented at every huddle. Establish this expectation during the first huddle and then hold staff accountable.

Run huddles in a consistent manner. To keep the ASC daily huddle functional and quick, follow the same direction every meeting. Establish the order for department representatives to speak and always proceed in that manner. Once participants become accustomed to that order, they will know when it’s their turn to speak, eliminating wasted time.

Daily Huddle Topics of Discussion

Representatives should come to each daily huddle prepared to speak about their departments’ specific concerns for the upcoming day. A concern one day may not be a concern the following day. If a matter is not a concern for the upcoming surgical day, it should not be raised during the huddle.

Here are examples of worthwhile topics staff may want to discuss, broken down by department.

Business office:

  • Appropriateness of check-in times
  • Patient comfort upon arrival
  • Staff comfort with patient flow
  • Ability for staff to handle unusual scheduling (e.g., add-on cases)
  • Patient financial issues that could delay the start of a case
  • Patients with similar names that could create safety issues

Pre-op:

  • Assessment concerns
  • Missing paperwork (e.g., history and physicals, consent forms)
  • Noteworthy patient health issues (e.g., fall risks, poor vision or hearing)

OR:

  • Challenging surgeries, surgical approaches, physicians or staff
  • Availability of instrument sets and supplies
  • Availability of required implants
  • Status of vendors expected to participate in procedures

CSPD:

  • Challenging instrument turnovers that could delay cases

PACU:

  • Discharge red flags
  • Appropriate staffing levels for patient flow/timing
  • Potential need for extended shifts

ASC Daily Huddle Success: Final Key Takeaways

When beginning with huddles, the first few might take longer than you desire. That’s to be expected as staff learn about and become comfortable with how you want to approach each daily huddle.

Provide guidance to participants on topics they should and should not discuss. Remind them about the importance of coming to the daily huddle prepared. Help them with timing. If someone starts to ramble, reel them in. While structure is important, strive to keep huddles loose and full of positive energy.

With each passing week, the amount of time a daily huddle takes should decline. After a little while, huddles should rarely – if ever – exceed your maximum time allotted.

Most importantly, every daily huddle must provide value. Participants should share their thoughts about what they believe is necessary to improve operations. Staff should come away from a huddle knowing what must happen to make the upcoming surgical day safe and productive.


Jebby Mathew, Regional Director of Operations