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Dawn Q. McLane, RN, MSA, CASC, CNOR - Surveyor (10 Years) Accreditation Association for Ambulatory Health Care MNASCA - April, 2012. Accreditation Panel. Outline. Elements of a Successful Survey Update on 2012 AAAHC Accreditation Standards

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accreditation panel

Dawn Q. McLane, RN, MSA, CASC, CNOR -

Surveyor (10 Years)

Accreditation Association for Ambulatory Health Care

MNASCA - April, 2012

Accreditation Panel

Elements of a Successful Survey

  • Update on 2012 AAAHC Accreditation Standards
  • 5 Most Common Accreditation Problem Areas
  • CMS – Conditions for Coverage
  • Life Safety Code & Physical Environment Checklist
  • Questions/Discussion
step 1 be prepared
Step 1 : Be Prepared

Know what is new in 2012 AAAHC Standards

  • In the core chapters (1-8), the only changes were for consistency with glossary definitions
  • Chapter 9 (Anesthesia Services)
    • 9.R was revised to include patient safety as the focus of required written protocols regarding MH
    • 9.W was modified to clarify when it is applicable re: written protocol for how a deeper than intended level of sedation is occurs (anesthesiologist, CRNA, Anesthesia Assistant - if privileged, or oral maxillofacial surgeon is not present)
  • Chapter 10 (Surgical and Related Services)
    • 10.I.AA is a new Standard addressing written protocols for handling, maintenance and storage of blood/blood products and human cells or tissues consistent with nationally recognized authority like AATB or FDA.
step 1 be prepared1
Step 1 : Be Prepared
  • Accreditation Steps To Success
  • Achieving Accreditation Program, Standards Manual, PEC if Medicare certified
  • Application – electronically; attach required documents
  • Site Visit
  • Decision Letter
  • Survey Report

For Medicare deemed status survey (within 90 days of appl approval)


For Medicare deemed status survey


10 days

10 days

< 20 days

survey site visit
Survey Site Visit
  • Opening Conference
  • Tour - patient flow
  • Observation (of procedure)
  • Review of records, files, manuals, contracts
  • Review lab, pharmacy, imaging, generator, etc.
  • QI Conference
  • Interviews with staff
  • Summation Conference
step 2 know the pitfalls
Step 2 : Know The Pitfalls

5 Most Common Accreditation Problems

  • Patient Rights : advance directives, ownership disclosure, patient rights including how and where to file a grievance, prior to admission, posted in facility
    • Observe admission process
    • Review medical record for documentation
  • Adverse Incident Reporting System :
    • definitions of adverse incident (negative comment, complaint, grievance, incident, loss),
    • documented employee education and training,
    • job description,
    • tracking/trending/QI study
step 2 know the pitfalls1
Step 2 : Know The Pitfalls

3. Peer Review : move beyond chart reviews as only means of performance evaluation,

  • Unplanned admissions to acute care facility
  • Unexpected return to operating room same admission
  • Abnormal path reports
  • Facility incurred incidents (e.g. unscheduled vitrectomy, lost nucleus, bowel perforation, infections, scope to open procedure)
  • Failure to follow policies (IC, marking the site, time out, behaviors)
  • Patient Satisfaction Survey comments
  • Maintenance of Board Certification, if required
  • Timeliness of arrival, dictation, returned phone calls
step 2 know the pitfalls2
Step 2 : Know The Pitfalls
  • Quality / Performance Management :
    • stuck at the QA level with no corrective actions,
    • lack of external or internal benchmarking to establish performance goals,
    • reactive vs. proactive

5. Medicare/CMS Conditions for Coverage (CfC)

§416.49(b) Standard: Radiologic Services.

  • The ASC must have procedures for obtaining radiological services from a Medicare approved facility to meet the needs of patients.
  • Radiologic services must meet the hospital conditions of participation for radiologic services specified in §482.26 of this chapter.
step 2 know the pitfalls3
Step 2 : Know The Pitfalls
  • If the ASC uses radiological services as an integral part of the surgical procedures it performs, then, to meet the need of the ASC’s patients, those radiological services must be provided in a manner that complies with the hospital Condition of Participation for radiological services found at 42 CFR 482.26. If the ASC does not provide these radiological services directly, i.e., utilizing its own staff, then it must obtain them via a contract or other formal arrangement from a Medicare-approved, i.e., a Medicare-participating, facility. Radiological services integral to the procedure itself are those imaging services performed immediately before, during or after the procedure that are medically necessary to the completion of the procedure.
  • If an ASC does not perform any procedures where radiological services are integral to the procedure, then the ASC is not required by this regulation to have arrangements for obtaining radiological services.
step 2 know the pitfalls4
Step 2 : Know The Pitfalls
  • §482.26(c) Standard: Personnel

Interpretive Guidelines §482.26(c):

    • The hospital must ensure that specific radiology personnel requirements are met.
  • §482.26(c)(1) A qualified full-time, part-time or consulting radiologist must supervise the ionizing radiology services and must interpret only those radiologic tests that are determined by the medical staff to require a radiologist’s specialized knowledge. For purposes of this section, a radiologist is a doctor of medicine or osteopathy who is qualified by education and experience in radiology.
step 2 know the pitfalls5
Step 2 : Know The Pitfalls

Life Safety Code

  • 3.16 Exiting :
    • 30 second test every 30 days,
    • 90 minute test annual,
    • keep inspection records in a log book
  • 8.31.11 EES Equipment : protection from vandalism, sabotage, other intentional intrusion
  • 8.31.22 Alternate Power : self-contained, battery-powered emergency lighting
  • 8.32.1 Stored Emergency Power Supply System (SEPSS) : remote annunciation panel capability
thank you
Thank You


Surveyor (10 Years)

Accreditation Association for Ambulatory Health Care

5250 Old Orchard Drive, Suite 200

Skokie, Illinois 60077


Ray Grundman - AAAHC