AAAHC Accreditation for Ambulatory Surgery Centers Michon Villanueva Assistant Director, Accreditation Services Texas Ambu...
About AAAHC <ul><li>Over 4,500 currently accredited organizations </li></ul><ul><li>More than 330 trained surveyors, many ...
AAAHC Accreditation <ul><li>Largest accreditor of ASCs  </li></ul><ul><ul><li>2662 - Total </li></ul></ul><ul><ul><li>950 ...
AAAHC Standards for 2010 <ul><li>Please visit the AAAHC website for further details </li></ul><ul><li>Changes in all core ...
AAAHC Standards <ul><li>Core Chapters </li></ul><ul><ul><li>Rights of Patients </li></ul></ul><ul><ul><li>Governance </li>...
News <ul><li>11/10/09 – HHS Secretary Kathleen Sebelius announced that now 43 state survey agencies will be surveying 1300...
New CMS Conditions for Coverage (CfC) Electronic Code of Federal Regulations, Title 42, Public Health, Part 416 ASCs, Subp...
New ASC Survey Protocol <ul><li>Task 1 Off-Site Survey Preparation </li></ul><ul><li>Task 2 Entrance Activities </li></ul>...
Case Observation <ul><li>At least one procedure to be selected </li></ul><ul><li>Case selected should be one that is not e...
Case observation <ul><li>Compliance with the following will be assessed: </li></ul><ul><li>infection control </li></ul><ul...
Infection Control Worksheet <ul><li>CMS developed with CDC </li></ul><ul><li>Effective October 1, 2009 </li></ul><ul><li>U...
Revised ASC Conditions for Coverage effective May 18, 2009: <ul><li>Expanded Interpretive guidelines </li></ul><ul><li>Rev...
416.2 ASC Definition <ul><li>REVISED </li></ul><ul><li>Ambulatory surgical center  or  ASC  means: </li></ul><ul><li>disti...
416.41  Condition : Governing body and management <ul><li>AAAHC Surveyors will review GB minutes:  frequency of meetings a...
416.42  Condition : Surgical Services <ul><li>Review credentials files of Physicians: MD, DO,  DDS, DMD, DPM, OD, DC </li>...
416.42  Standards :  <ul><li>(a) Anesthetic risk and evaluation </li></ul><ul><li>Policies and procedures and medical reco...
416.43  Condition : Evaluation of Quality <ul><li>Review for evidence that QAPI program: </li></ul><ul><li>Is proactive an...
416.44  Condition : Environment <ul><li>Evaluation of compliance to ensure provision of surgical services in a safe and sa...
416.44  Standards : <ul><li>Emergency equipment </li></ul><ul><ul><li>Ensure compliance with required emergency equipment ...
416.45  Condition : Medical Staff Medical staff responsibilities are outlined and they are held accountable to the governi...
416.45  Standards :  <ul><li>(a) Membership and clinical privileges </li></ul><ul><li>Policies and procedures and credenti...
416.46  Condition : Nursing Service <ul><li>Nursing services must be under direction of an RN.  </li></ul><ul><li>Review: ...
416.47 Condition: Medical Records <ul><li>Ensure ASC maintains  complete ,  comprehensive , and  accurate medical records ...
<ul><li>Interview with licensed healthcare professional designated responsible – evidence of active direction and oversigh...
416.49  Condition : Laboratory and radiologic services <ul><li>AAAHC Surveyors will determine: </li></ul><ul><li>If ASC pe...
416.49  Standard : (b) Radiologic services <ul><li>If ASC does not provide radiologic services and is integral to procedur...
Questions: <ul><li>AAAHC has four regional corps: </li></ul><ul><li>East  </li></ul><ul><li>West </li></ul><ul><li>Central...
Regional Corps for Texas Regional Manager  Dan Vincent (847) 853-6065 Application Coordinator Lenny Wojt (847) 324-7725 Sc...
Michon Villanueva (847) 853-6063 / mvillanueva@aaahc.org AAAHC  “ The Accreditation Association” Phone:  847-853-6060 Web ...
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AAAHC Presentation

  1. 1. AAAHC Accreditation for Ambulatory Surgery Centers Michon Villanueva Assistant Director, Accreditation Services Texas Ambulatory Surgery Center Society Annual Conference Dallas, TX – November 13, 2009
  2. 2. About AAAHC <ul><li>Over 4,500 currently accredited organizations </li></ul><ul><li>More than 330 trained surveyors, many are physicians, from all types of health care organizations </li></ul><ul><li>AAAHC Board expertise, committees & task forces examine every issue related to ambulatory accreditation and every new trend impacting on accreditation or quality of care. </li></ul>
  3. 3. AAAHC Accreditation <ul><li>Largest accreditor of ASCs </li></ul><ul><ul><li>2662 - Total </li></ul></ul><ul><ul><li>950 - Medicare deemed status </li></ul></ul><ul><ul><li>157 – accredited ASCs in Texas </li></ul></ul><ul><ul><li>65 – deemed ASCs in Texas </li></ul></ul><ul><li>Recognized by state agencies </li></ul><ul><ul><li>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 </li></ul></ul>
  4. 4. AAAHC Standards for 2010 <ul><li>Please visit the AAAHC website for further details </li></ul><ul><li>Changes in all core chapters, including new Chapter 7 </li></ul><ul><li>Changes to the many adjunct chapters including: </li></ul><ul><ul><li>Anesthesia Services </li></ul></ul><ul><ul><li>Surgical Services </li></ul></ul><ul><ul><li>Diagnostic and Other Imaging Services </li></ul></ul>
  5. 5. AAAHC Standards <ul><li>Core Chapters </li></ul><ul><ul><li>Rights of Patients </li></ul></ul><ul><ul><li>Governance </li></ul></ul><ul><ul><li>Administration </li></ul></ul><ul><ul><li>Quality of Care Provided </li></ul></ul><ul><ul><li>Quality Management and Improvement </li></ul></ul><ul><ul><li>Clinical Records and Health Information </li></ul></ul><ul><ul><li>Infection Control and Prevention and Safety (2010) </li></ul></ul><ul><ul><li>Facilities and Environment </li></ul></ul><ul><li>Adjunct Chapters </li></ul><ul><ul><li>9. Anesthesia Services </li></ul></ul><ul><ul><li>10. Surgical and Related Services </li></ul></ul><ul><ul><li>Others, as appropriate </li></ul></ul>
  6. 6. News <ul><li>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. </li></ul><ul><li>7/27/09 – HHS Secretary Kathleen Sebelius announces the oversight of the HIPAA Security Rule has been delegated to the Office of Civil Rights </li></ul><ul><li>7/1/09 - California became the 15 th state to opt-out of physician supervision of CRNAs (416.42(c)(1)) </li></ul>
  7. 7. 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
  8. 8. New ASC Survey Protocol <ul><li>Task 1 Off-Site Survey Preparation </li></ul><ul><li>Task 2 Entrance Activities </li></ul><ul><li>Task 3 Information Gathering/Investigation </li></ul><ul><li>Task 4 Preliminary Decision-Making and Analysis of Findings </li></ul><ul><li>Task 5 Exit Conference </li></ul><ul><li>Task 6 Post-Survey Activities </li></ul>
  9. 9. Case Observation <ul><li>At least one procedure to be selected </li></ul><ul><li>Case selected should be one that is not expected to exceed 90 minutes </li></ul><ul><li>Surveyor will follow patient from pre-op to recovery/discharge </li></ul>
  10. 10. Case observation <ul><li>Compliance with the following will be assessed: </li></ul><ul><li>infection control </li></ul><ul><li>physical environment </li></ul><ul><li>medication administration, </li></ul><ul><li>assessment of anesthesia and procedure risk </li></ul><ul><li>pre-operative update assessment of changes from the H&P </li></ul><ul><li>provision of surgical and anesthesia services </li></ul><ul><li>post-surgical assessment </li></ul><ul><li>recovery from surgery and anesthesia </li></ul><ul><li>discharge orders </li></ul>
  11. 11. Infection Control Worksheet <ul><li>CMS developed with CDC </li></ul><ul><li>Effective October 1, 2009 </li></ul><ul><li>Used by state agencies and Accrediting Organizations (AOs) </li></ul><ul><li>One surveyor must complete – includes input from survey team </li></ul><ul><li>Documentation of direct observation and interviews </li></ul><ul><li>Specifically requires interviews with staff responsible for a particular function </li></ul>
  12. 12. Revised ASC Conditions for Coverage effective May 18, 2009: <ul><li>Expanded Interpretive guidelines </li></ul><ul><li>Revisions made to the requirements for many existing Conditions </li></ul><ul><li>Three new conditions: </li></ul><ul><ul><li>416.50 Patient Rights </li></ul></ul><ul><ul><li>416.51 Infection Control </li></ul></ul><ul><ul><li>416.52 Patient Admission, Assessment and Discharge </li></ul></ul>
  13. 13. 416.2 ASC Definition <ul><li>REVISED </li></ul><ul><li>Ambulatory surgical center or ASC means: </li></ul><ul><li>distinct entity </li></ul><ul><li>physical separation by at least a 1-hour separation </li></ul><ul><li>only surgical* services not requiring hospitalization </li></ul><ul><li>has agreement with CMS as an ASC meet 42 CFR 416 </li></ul><ul><li>surgical procedures not expected to exceed 24 hrs </li></ul><ul><li>time documented in clinical record: </li></ul><ul><ul><li>Admission </li></ul></ul><ul><ul><li>discharge order signed by MD/ Pt exits recovery room </li></ul></ul><ul><li>exceptional cases documented clearl y </li></ul><ul><li>{*Definition of surgery adopted from American College of Surgeons ( www.facs.org/fellow_info/statement/st-11.html )} </li></ul>
  14. 14. 416.41 Condition : Governing body and management <ul><li>AAAHC Surveyors will review GB minutes: frequency of meetings and agenda items </li></ul><ul><ul><li>Evidence of monitoring, oversight and accountability </li></ul></ul><ul><ul><ul><li>Review of delegated responsibilities </li></ul></ul></ul><ul><ul><ul><li>Compliance with policies, including written disaster preparedness </li></ul></ul></ul><ul><ul><ul><li>QAPI </li></ul></ul></ul>
  15. 15. 416.42 Condition : Surgical Services <ul><li>Review credentials files of Physicians: MD, DO, DDS, DMD, DPM, OD, DC </li></ul><ul><ul><li>Licensed </li></ul></ul><ul><ul><li>Criteria for privileging / specific list of privileges granted </li></ul></ul><ul><li>Determine provision of surgical services in a safe manner: </li></ul><ul><ul><li>Compliance with state and federal laws </li></ul></ul><ul><ul><li>Compliance with acceptable standards of practice </li></ul></ul><ul><ul><ul><li>AMA / ACOS / AORN / APIC </li></ul></ul></ul><ul><ul><li>Compliance with other CfC: 416.43-45, 416.51-2 </li></ul></ul>
  16. 16. 416.42 Standards : <ul><li>(a) Anesthetic risk and evaluation </li></ul><ul><li>Policies and procedures and medical record review: </li></ul><ul><li>Assessment for anesthesia risk prior to procedure </li></ul><ul><li>Evaluation of patient for proper anesthesia recovery </li></ul><ul><li>Administration of Anesthesia </li></ul><ul><li>Anesthesiologist </li></ul><ul><li>CRNA (physician supervision unless in opt-out state) </li></ul><ul><li>Anesthesiology assistant (supervised by physician) </li></ul><ul><li>State exemption – opt-out states </li></ul><ul><li>Iowa New Hampshire Washington </li></ul><ul><li>Nebraska New Mexico Alaska </li></ul><ul><li>Idaho Kansas Oregon </li></ul><ul><li>Minnesota North Dakota South Dakota </li></ul><ul><li>Wisconsin Montana California – 7/1/09 </li></ul>
  17. 17. 416.43 Condition : Evaluation of Quality <ul><li>Review for evidence that QAPI program: </li></ul><ul><li>Is proactive and ongoing </li></ul><ul><li>Is comprehensive and data driven – process and frequency of data collection and analysis </li></ul><ul><li>Evaluates systems, policies, practices, processes or events to identify problems that have occurred or may occur </li></ul><ul><li>Requires the determination of the root cause of problems </li></ul><ul><li>Results in effective actions to correct problems </li></ul><ul><li>Requires follow up to ensure performance improvement </li></ul>
  18. 18. 416.44 Condition : Environment <ul><li>Evaluation of compliance to ensure provision of surgical services in a safe and sanitary environment that is properly constructed, equipped and maintained. </li></ul><ul><li>Evaluation of Life Safety Code compliance </li></ul>
  19. 19. 416.44 Standards : <ul><li>Emergency equipment </li></ul><ul><ul><li>Ensure compliance with required emergency equipment </li></ul></ul><ul><ul><ul><li>Use of cricoidotomy set in place of tracheostomy set </li></ul></ul></ul><ul><ul><ul><li>AED may be used if ASC determines appropriateness for types of patients served </li></ul></ul></ul><ul><li>(d ) Emergency personnel </li></ul><ul><ul><li>Review personnel files </li></ul></ul><ul><ul><ul><li>Training and competence to use emergency equipment and supplies </li></ul></ul></ul><ul><ul><ul><li>CPR training </li></ul></ul></ul><ul><ul><ul><li>Staffing to ensure such personnel are present when there is a patient in the ASC </li></ul></ul></ul>
  20. 20. 416.45 Condition : Medical Staff Medical staff responsibilities are outlined and they are held accountable to the governing body
  21. 21. 416.45 Standards : <ul><li>(a) Membership and clinical privileges </li></ul><ul><li>Policies and procedures and credentials and personnel record review: </li></ul><ul><ul><li>State licensure, certifications </li></ul></ul><ul><ul><li>Relevant training and experience </li></ul></ul><ul><ul><li>Recommendations by qualified medical personnel </li></ul></ul><ul><ul><li>Specific list of privileges granted </li></ul></ul><ul><li>Reappraisals </li></ul><ul><ul><li>Reappointment, including peer review </li></ul></ul><ul><li>Other practitioners </li></ul><ul><ul><li>Licensed practitioners (non-MD or RN) </li></ul></ul><ul><ul><li>Qualifications </li></ul></ul><ul><ul><li>Supervision </li></ul></ul><ul><ul><li>Evaluation of performance </li></ul></ul>
  22. 22. 416.46 Condition : Nursing Service <ul><li>Nursing services must be under direction of an RN. </li></ul><ul><li>Review: </li></ul><ul><li>Qualifications </li></ul><ul><li>Responsibilities </li></ul><ul><li>Staffing </li></ul><ul><li>Organization and staffing </li></ul><ul><ul><li>Clear, written responsibilities (job description) </li></ul></ul><ul><ul><li>Nursing services consistent with “recognized standards of practice” (State laws and nationally recognized standards/guidelines, e.g., ANA, AORN) </li></ul></ul><ul><ul><li>Verify RN with (ACLS) is on premises and sufficiently free from duties to respond rapidly to emergency situations </li></ul></ul>
  23. 23. 416.47 Condition: Medical Records <ul><li>Ensure ASC maintains complete , comprehensive , and accurate medical records ; review policies and procedures and medical records: </li></ul><ul><li>Organization </li></ul><ul><ul><li>Interview with designated responsible for clinical records </li></ul></ul><ul><ul><li>Description of system </li></ul></ul><ul><ul><li>Collected and stored in a consistent manner </li></ul></ul><ul><ul><li>Timely access </li></ul></ul><ul><li>Form and Content of Record </li></ul><ul><ul><li>Patient identification </li></ul></ul><ul><ul><li>Significant medical history and results of physical examination </li></ul></ul><ul><ul><li>Pre-op diagnostic studies (entered before surgery), if performed </li></ul></ul><ul><ul><li>Findings / techniques of operation including path report on all tissues removed during surgery, except those exempted by GB </li></ul></ul><ul><ul><li>Any allergies and abnormal drug reactions </li></ul></ul><ul><ul><li>Entries related to anesthesia administration </li></ul></ul><ul><ul><li>Documentation of properly executed informed patient consent </li></ul></ul><ul><ul><li>Discharge diagnosis </li></ul></ul>
  24. 24. <ul><li>Interview with licensed healthcare professional designated responsible – evidence of active direction and oversight </li></ul><ul><li>(a) Administration of drugs </li></ul><ul><li>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 </li></ul><ul><li>Staff responsibilities regarding prescription pad security, security of controlled and non-controlled substances, and drug recalls </li></ul><ul><li>Safe practices for the use of single use syringes and needles and multi-dose vials </li></ul><ul><li>Pharmaceutical logs/inventory/wastage, including samples </li></ul><ul><li>Pharmacy consultant contract (if applicable) </li></ul>416.48 Condition : Pharmaceutical Services
  25. 25. 416.49 Condition : Laboratory and radiologic services <ul><li>AAAHC Surveyors will determine: </li></ul><ul><li>If ASC performs laboratory services: </li></ul><ul><li>Must have current CLIA Certificate or CLIA Waiver </li></ul><ul><li>If ASC does not provide laboratory services: </li></ul><ul><li>Must have procedures and well-defined contract for obtaining routine and emergency laboratory services from certified laboratory </li></ul>
  26. 26. 416.49 Standard : (b) Radiologic services <ul><li>If ASC does not provide radiologic services and is integral to procedures performed: </li></ul><ul><li>Must have procedures for obtaining radiological services from a Medicare approved facility </li></ul><ul><li>If ASC provides radiologic services: </li></ul><ul><li>Meets hospital CoPs for radiologic services specified in §482.26 ( Radiologic services ) </li></ul>
  27. 27. Questions: <ul><li>AAAHC has four regional corps: </li></ul><ul><li>East </li></ul><ul><li>West </li></ul><ul><li>Central </li></ul><ul><li>Global </li></ul><ul><li>For questions about AAAHC accreditation or AAAHC/Medicare Deemed Status, ASCs in Texas please contact the AAAHC Central corps . </li></ul>
  28. 28. 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 Warman Denisa Mateev (847) 324-7737 (847) 324-7740
  29. 29. Michon Villanueva (847) 853-6063 / mvillanueva@aaahc.org AAAHC “ The Accreditation Association” Phone: 847-853-6060 Web site: www.aaahc.org E-mail: info@aaahc.org Contact AAAHC
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