When preparing for an accreditation survey, many facility managers focus their efforts on the facility itself. Accreditation experts universally agree, however, that a sparkling OR is no guarantee of accreditation success. In fact, the biggest accreditation mistake is placing too much focus on the physical condition of the facility and not enough on those less material issues designed to protect the patient-such as policies and procedures, credentialing, and charting. "Accreditation is not just about the OR and the crash cart," says Ronald E. Iverson, MD, FACS, President of the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) in Pleasanton, Calif. "It is a process that involves every aspect of the facility." In this article, we review the most common accreditation hurdles and offer tips on how you can clear them.

1. Irrelevant or Incorrect Policies and Procedures
Policies and procedures that do not reflect what the facility is actually doing represent a big accreditation mistake. Accreditation specialists cite all sorts of examples-ranging from procedures for the outmoded ?clean and dirty' sterilization technique, to policies referencing nonextant sterilization equipment or eyewash stations, to those promising authentication of all verbal orders within 24 hours when, in fact, actual practice has taken up to 30 days. Experts say there are three reasons why these problems occur:

1. Uncensored use of others' policies and procedures. When you use policies and procedures originally written for someone else, you risk being inaccurate. For example, notes Joni Steinman, managing principal of AUSMS Healthcare Consultants in San Diego, hospital policies should reflect different standards for patient discharge than ASC policies. "Standards for discharge of a patient in a hospital are usually criteria-based. The physician does not need to see the patient before discharge," she says. "In a surgery center, the physician must see the patient before the patient is released, and you must document this visit."

To prevent this problem, experts advise one of two approaches. If you use pre-prepared consultants' manuals or policies from other hospitals or ASCs, says Barbara Ann Harmer, RN, BSN, MHA, an Accreditation Association for Ambulatory Health Care (AAAHC) surveyor and Director of Surgical Services with Celebration Health in Celebration, Fla., be acutely aware of what those policies say and modify them to reflect your specific practices. Alternately, write your own policies and procedures from scratch. "Policies and procedures should really be developed by the staff," advises Ms. Steinman. "It's the only way to match up what you do with what you say you do."

2. Policies written for the surveyor. Some facilities write policies based on what they think the surveyor wants, rather than on what the facility actually does. "It doesn't matter as much what is in the policy," advises Donna Quinn, RN, BS, MBA, Director of the Orthopaedic Surgery Center in Concord, N. H. "Just let it reflect actual practice."

3. Idle policies. If policies and procedures sit idle, they can quickly become irrelevant or outmoded. "If you are not using them regularly, the staff may be operating under erroneous or outdated conditions," says Ms. Steinman. If, for example, someone changes a procedure in writing without informing and training the staff about the change, the facility can find itself in trouble during the next accreditation survey.

2. Incomplete Medical Charts
If anything puts a surveyor on the alert, it's incomplete or sloppy medical charts. Unfortunately, this serious problem is common. "If charts are sloppy, the rest of the facility is going to be sloppy, and you probably have something wrong," says James A. Yates, MD, an AAAASF surveyor and plastic surgeon who practices in Camp Hill, Pa. "If the charting is pristine, however, my level of concern about what's happening to patients at the facility lessens." Common charting problems cited by accreditation specialists include:

• Failure to document allergy status. You must document the presence or absence of patient allergies in the same place in each record, according to Ms. Harmer. "The key here is presence or absence. Some people miss this and only document allergies when they exist," she explains.
• Loose papers. A disorganized chart with loose papers can lead the surveyor to believe that the chart is not secure or confidential, say accreditation experts.
• Incomplete forms. When you leave blank spaces on medical forms, the surveyor will consider the medical record incomplete. "If blanks consistently occur, just revise the form," advises Ms. Harmer.
• Missing signatures. All patient sign-outs and orders-including the informed consent, transfer notes, discharge sheet, and verbal orders-must be backed by appropriate signatures. The anesthesia discharge signature, in particular, is commonly missing, according to Ms. Quinn.

3. Insufficient Credentialing
Although most outpatient facilities honestly attempt to credential their licensed independent practitioners, many fail to do so in a way that satisfies the accrediting organizations. This is especially true for freestanding ASCs; the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) cited inconsistent credentialing as the second most problematic ambulatory care standard in 2000. This is an easy area to trip up on, says Sandy Lieberman, MSW, Associate Director of Surveyor Management and Development with JCAHO, because credentialing involves so much detail work-such as licensure updating and verification, DEA controlled substance certifications, documented training for new procedures, recredentialing every two years, malpractice insurance verification, and sometimes letters of recommendation. Often, ASCs do not have dedicated staffers to do this work. "Many organizations don't put in all the resources they need to be sure every ?i' is dotted and every ?t' is crossed," she comments.

Facilities tend to overlook the need to make independent credentialing decisions. "You cannot simply go to the hospital, take the file on Dr. Smith, bring it back to your facility, and use it as your credentialing documentation," says Ms. Harmer. You can, however, use the hospital file as a starting point, provided Dr. Smith signs a release and you confirm the information independently. That means having your credentialing committee review the information, obtaining primary or secondary source verification of licensure (an AAAHC standard), and making an independent judgment, says Ms. Harmer.

The verification of licensure for all licensed practitioners-whether MDs, RNs, LPNs, or CRNAs-is a particular sticking point for many surveyors. Simply making a photocopy of a state license for the file does not prove the nurse or doctor actually has a license, warns Ms. Harmer. "Verification of licensure means you go to your state's authorizing agency, such as the state board of nursing, to ensure currency, lack of restrictions or sanctions, and validity," she says.

4. Inappropriate Privileging
Privileging is another problem area for ASCs because some facilities simply bridge privileges from the local hospital over to the ASC. According to Ms. Lieberman: "Privileges need to be site-specific because they reflect not only the competence of the provider but the setting ? Someone may be privileged to perform brain surgery at the hospital but the ASC setting cannot support this."

To prevent inappropriate privileging, say experts, ASCs can take privileging information from the external source, but they need to create their own list and make an independent judgment. "The privileging documentation needs to be in writing and in the minutes from your governing body meetings," says Ms. Harmer. "You must demonstrate that your governing body made an independent decision."

When doing so, know what your chosen credentialing organization requires. An important distinction between accrediting organizations, according to Dr. Iverson, is differing privileging requirements. "We [the AAAASF] require all individuals who operate in an ASC to be American Board of Medical Specialties (ABMS) board certified and have equivalent rights in a hospital," says Mr. Iverson. "Some dermatologists, for example, may not have hospital privileges to perform liposuction. They wouldn't meet our standards."

5. Inadequate Quality Improvement Studies
Surveyors and consultants alike cite quality improvement as one of the most egregious problem areas. Outpatient facilities, they say, do not always perform the quality improvement studies required by the accrediting organizations, and when they do, they often conduct them artificially or haphazardly. It is imperative, notes Adam F. Dorin, MD, MBA, AAAHC surveyor, and Chief of the Department of Anesthesiology with Maryland General Hospital, to perform studies with clear objectives that are designed to improve your quality management system, and to follow-through with legitimate analyses.

Although the accrediting organizations leave much up to the facility when it comes to designing and implementing quality improvement studies, experts offer the following tips for success:

• Use outcomes data. AAAHC and JHACO standards require facilities to incorporate some form of outcomes analysis into the quality assurance system, according to Dr. Dorin. He says this does not have to be sophisticated (you can use data forms with a number 2 pencil), but it must be outcomes-based. The idea is to prevent artificial study designs and unfounded conclusions. "You must let the data speak for itself," he advises.
• Keep it simple. According to Ms. Harmer, too many facilities hide behind lengthy reports and murky study objectives. "Don't try to be Microsoft or Chrysler," she advises. The best studies, she says, cut across administrative, clinical, and cost-of-care issues. She cites one such study that addressed the reasons why patient rides consistently showed up late. "Whenever you keep patients on site too long, this increases your risk management in all areas," she notes.
• Don't confuse an audit with a study. According to Ms. Harmer, an audit can form the basis of a study but does not replace a study. "If an audit of your medical records shows that 30 percent of histories and physicals are expired according to your policies and procedures," she explains, "this forms the basis for a study but is not, in itself, a study."
• Allow enough time for follow-up. For each study, you must follow-up with corrective action (when needed) and further evaluation. "After you determine and implement your action plan, you want to collect some more data over a reasonable timeframe to ensure you have corrected the problem," advises Ms. Harmer. "Don't just look at things two weeks after the study and assume the problem is solved."

6. Untested Security and Safety Plans
Accrediting organizations require you to not only conduct emergency and fire drills, but to document the time, date, and details of each drill and critique your performance. "You need to document what you did right, what you did wrong, what you will do better next time," says Susan Irvin, a consultant with Nashville, Tennessee-based Surginet, Inc. For example, says Ms. Quinn, someone should take the daily OR schedule in the case of evacuation so you can account for all patients and staff, and there should be a dedicated meeting place. You should also have communication plans in place in case of a power or telephone outage. Consider, too, what you would do in the case of water contamination, malfunctioning sterilizers, or a natural disaster.

According to experts, this level of detail often goes unaddressed, especially in smaller facilities that do not have personnel dedicated to managing these plans. If you manage a freestanding facility, Ms. Quinn advises obtaining the local hospital's plans if possible. "You cannot whip up these plans before the surveyor arrives. You need to let the staff review them, and you need to educate the staff on the procedures," she advises. "The surveyor is likely to quiz your staffers directly about this."

7. Inadequate Human Resource Standards
In the year 2000, the most problematic JCAHO ambulatory care standard involved assessing staff abilities. "Facilities may be assessing these abilities, but they may not be doing it effectively," notes Ms. Lieberman. "A lot of people feel they have selected someone through the recruitment process and assume the person can do everything they were hired to do."

To effectively assess staff competencies, experts recommend observing employees in action rather than asking them about their capabilities. The capabilities must also be tailored to the age of the population you are treating. Finally, advises Ms. Irvin: "Remember to include a competency assessment in the area of life safety and emergency preparedness."

8. Lack of Preparation
According to Gayle Evans with Kennesaw, Georgia-based Continuum Healthcare Consultants, Inc., accrediting organizations want to see a minimum of six months, preferably a year, of documentation. This includes everything from quality improvement studies, board meeting notes, appropriate policies and procedures, and more. However, advises Nancy Burden, MSML, RN, CPAN, CAPA, with Morton Plant Mease Health Care in Palm Harbor, Fla., this does not mean you can begin preparing six months before the survey and expect smooth sailing. According to Ms. Burden, it is essential to read and fully absorb the accreditation standards before implementing them. "You need to continually educate and ?inculturate' the staff," she says, "because these are standards you are supposed to be meeting all the time."

Thorough staff preparation and participation is increasingly important, agrees Brian Matson, a senior manager with the Indianapolis-based V4 Consulting, because surveyors are now making direct contact with anyone who plays an active role in the organization. This includes the entire clinical staff, as well as non-clinical personnel-such as those involved with registration, reception, billing, and clinical coding, as well as active volunteers. "The medical director absolutely must be there," adds Ms. Evans. "Physicians may think that is best for them to stay out of the way ? but a lot of the surveyors are physicians, and sometimes it's best for physicians to speak to other physicians."

To prepare your staff, experts offer several tips. First, advises Ms. Burden, reassure them. While preparing for accreditation of her facility, Ms. Burden discovered that many of her staffers were nervous and afraid they'd say the wrong thing, so she took steps to comfort them. "I tell them there's nothing you can say that's so big we will not receive accreditation, that we might get a type I but we'll have a chance to fix it," she offers. "I also tell them they'll never be alone with the surveyor." Second, advise your staff to avoid making up answers. "Best practice is to tell the surveyor I don't know, but I know where to find the answer," advises Leigh Anderson, President of AccreditationHQ, a consulting firm in Redlands, Calif. Finally, and perhaps most importantly, experts recommend doing a mock survey. "In today's healthcare environment, a number of organizations are so desperate for personnel that they fail to provide a proper orientation process that might include policy and procedure review, competency assessment, job shadowing, or other methods," says Mr. Matson. "On previous mock surveys, I've seen nurses in the same surgery center prepping patients for surgery using two different processes?One nurse stated that she was merely using the same method she had used at her previous employer, a local hospital. She didn't even know that a policy and procedure existed to address the prep process," he says. The mock survey can help you target and eliminate these problems well before the survey day.

A Consultative Bent
Fortunately, the accreditation process can yield many more rewards than just a certificate to hang on your wall. "It's not just a stamp of approval," notes Ms. Evans. "Going through the process can actually help you improve care."

To get the maximum benefit and minimize stress, experts advise approaching the process like a consultation, not a test. Allow yourself to challenge the surveyor if necessary, they say, but do not be argumentative or defensive. "We have background and knowledge, and we like when the staff is present to hear our comments and learn," says Dr. Yates. Tammy Ham, with Kansas City, Missouri-based Ambulatory Surgery Assistance, Inc., agrees: "There is a big myth about how frightening surveyors can be," she says. "Most of the time they are extremely accommodating. Remember, they are there to accredit you, not discredit you!"