Regulatory Affairs: Remain Compliant Between Surveyor Visits

Stay current with updates from your accrediting body to ensure safety.

Accreditation is a crucial element of a successful ASC. It positions a new facility to receive Medicare funding in months, compared to potentially waiting for a year or more to receive certification from your state health department.

This does more than kickstart your Medicare caseload. Securing Medicare Deemed Status is also often required before you can negotiate contracts with commercial insurers. Other benefits include improving patient care, instilling a culture of safety and increasing community confidence in your facility.

Keep abreast of new standards

Once you get accredited, however, you shouldn’t coast on the achievement until it’s time to reaccredit. New regulations and best practices come at you fast, and it’s your responsibility to stay abreast of changes.

For example, the Accreditation Association for Ambulatory Health Care (AAAHC), which has accredited more than 6,700 organizations, issues three-year certifications, but released updates to its standards in December that will go into effect this month.

“We expect our organizations to apply the changes even if they’re not scheduled to be surveyed this year,” says Frank Chapman, chairman of the AAAHC Standards Development Committee. “This goes beyond writing a new policy. We expect them to train their staff on the changes that occur during the entire term of accreditation.”

Be sure to stay current on updates such as these, no matter which accrediting body you use. Here are the most significant AAAHC updates:

• Alternatives to transfer agreements. Every ASC once needed a written agreement with a nearby hospital that said it would accept patient transfers in case they needed emergency or higher levels of care. The need for such agreements relaxed over the years in instances when all the surgeons performing procedures at an ASC had admitting privileges to the hospital. And the U.S. Emergency Medical Treatment and Labor Act essentially renders such agreements moot, as the federal law requires emergency rooms to accept, examine and stabilize all patients who arrive for care. Also, the ambulance company that picks up a patient makes the final call as to which hospital they will take a patient.

The updated version of AAAHC’s standards eliminates the requirement for a document that codifies the transfer agreement. The focus is now on the transfer process itself to make sure facilities are ready should a transfer become necessary.

The update includes guidance on what documentation should accompany the patient, such as their latest history and physical forms (H&Ps), as well as their recently completed operative report. There is also a discussion as to when and how to notify the patient’s friend or loved one who accompanied the patient to the surgery center.

• Flexible history and physical policies. Previously, AAAHC required that H&Ps be crafted no more than 30 days before surgery. The same standard applied to patients undergoing office-based cases, such as a dermatological procedure with a topical anesthetic, as it did to someone facing a total knee replacement.

“We listened to our organizations and concluded that one size doesn’t necessarily fit all,” says Mr. Chapman. “We now leave it up to the organization to craft H&Ps that are established on procedure type and include a timeframe for completion.”

Organizations should base the new H&Ps on nationally recognized standards of practice and guidelines from specialty societies that are experts in the respective service lines applicable to the services offered. Providers also must remember to update the H&Ps with new information prior to the procedure, such as changes in medications and whether patients have had new illnesses since the original H&P was created.

• Evaluate anesthesia risks. Another updated standard requires a surgeon or other appropriate OR team member to evaluate the patient, immediately before an operation, for their risk to the anesthesia, says AAACH President and CEO Noel Adachi.

This is the second of two patient assessments, says Mr. Chapman. The first one, typically done by the surgeon, looks at the condition of the patient to determine whether they can tolerate the procedure. The second one determines whether the patient will be able to tolerate the anesthesia and could be performed by the physician in cases where conscious sedation is used and there isn’t an anesthesia professional on the team. Otherwise, a CRNA, anesthesiologist or anesthesiologist assistant should do the assessment. In some circumstances, an anesthesia professional can conduct the assessment in the pre-op area and need not be in the OR when the procedure is done, as long as they are recorded as a member of the surgical team.

• Revamped communicable diseases policy. Before this standard was updated, it included a provision for written policies and procedures that required the isolation and immediate transfer of patients with contagious conditions.

“With COVID, we found out very quickly that most ambulatory organizations don’t have the capacity to truly isolate a patient, as hospitals do with HVAC systems in isolation rooms that don’t circulate air to the rest of the building,” says Mr. Chapman. “And pre-COVID, you would generally transfer someone with something communicable to the hospital, which isn’t always appropriate with COVID, and might not be for whatever might come next.”

The new standard requires written policies and procedures that include an appropriate referral of care, depending on the disease. A COVID case, for example, might require a referral to their primary care physician. The non-disease-specific wording is designed to allow facilities to craft responses appropriate for a variety of ailments and situations.

• Choose wisely. Ms. Adachi says a good accreditation body guides organizations with comprehensive standards to ensure a quality safe environment for patients, staff and visitors. “When you choose accreditors, you’re looking at their focus, the experience base of the surveyors and the applicability and relevance of the standards to the unique attributes of your ambulatory surgery center,” she says. “We try to fill that demand with relevant, collegial-but-rigorous, education-focused surveys with professionals who’ve walked in the shoes of ASC staff and understand their challenges.” OSM