Dermatology Office Accreditation

Preparation

The surveyed organization should prepare at least 1 year in advance for an accreditation survey ( Box 52.3 ). Information is reviewed about patients including: patient services, satisfaction, clinical records, patient handouts, marketing materials, and statements of patients' rights and responsibilities ( Box 52.3 ). Items needed about physicians and other staff members include: personnel records, board certification, and continuing education schedules. Other logistic details must be supplied including emergency drills, maintenance, lab statistics, committee and governing body meetings, credentialing and privileging policies, audit and balance sheets, Medicare reports, and quality improvement.

A mock survey can be incredibly helpful when organizing an office for the items which need attention prior to the accreditation survey. Assistance from consultants can be particularly helpful in preparing for a survey. In recognition of the need for quality consultative guidance, The AAAHC established Healthcare Consultants International to provide office-based policy and procedure manuals, telephone consults, and on-site training.

Accreditation survey

An accreditation survey reviews every aspect of the practice, not just the physical environment, and surveyors will take time to check a number of policies and procedures. Documents reviewed during an accreditation survey should be prepared in advance ( Box 52.3 ). The purpose of this review is to make sure the surveyed organization is doing what it says it is. Similar to the clinical record, if it is not written down, it did not happen.

The accreditation surveyor inspects the facilities and environment during an initial orientation tour and observes a typical surgical procedure. Medical equipment must have completed, dated maintenance tags to show that it is in proper working order. All medications and materials in the surgical area and crash cart must be up-to-date. There should be a stipulated safe handling procedure for narcotic medications. A surgical procedure will be observed to ensure that proper sterile technique is followed, to assess surgical skill, and to follow postoperative recovery. Other important items include quality improvement and infection control.

The accreditation survey is usually performed by one to two surveyors over about 1–1.5 days, depending on the size and scope of the organization. During this time, the surveyors may directly ask questions to the staff informally or during formal interviews.

Sample questions may include:

• What do you think is good about the organization and what should be changed?

• Would you bring your family members to be seen as patients here?

• Are you happy with your employment?

• Are you aware of a policy or procedure for a particular activity?

• Are you involved in quality improvement?

• How is information shared within the organization?

• What are you most proud of in the organization?

Personnel should answer these questions honestly and should avoid fabricating their answers. If they are unable to answer a particular question, they should say, “I do not know the answer but I know where I can find the answer.” The personnel should be reassured by the surveyed organization that their comments will not be the cause of a failure to achieve accreditation nor will their responses result in punitive treatment.

Documented policies, procedures, credentialing, privileging, quality improvement, and risk management activities are points of emphasis by the surveyors.

Summation conference

The surveyors will report the findings to the healthcare organization at a summation conference, which involves dialogue between the surveyors and the principals of the organization. For accreditation organizations other than Medicare, it will take approximately 2–4 weeks for a decision to be announced.

Survey report and accreditation decision

After the summation conference, a survey report is submitted to an accreditation committee, which decides whether or not accreditation is granted. The process takes approximately 2–4 weeks. The AAAHC has recently limited its decisions to that of a 3-year accreditation term and denial of accreditation. The healthcare organization always has the right to appeal against the decision. The AAAHC can also choose to conduct an interim survey during the 3-year period if there were certain deficiencies noted on the previous survey, in order to assess compliance with AAAHC standards.

Survey process

Following the receipt of a completed application from an organization, the AAAHC starts the scheduling process for the survey :

• The size and range of services being offered by the organization seeking accreditation are what determine the length of the on-site visit, the number of surveyors needed, and the survey fee.

• Survey dates are determined by the accreditation association's scheduling office, in cooperation with the organization being surveyed.

• The expertise of the survey team members is matched as closely as possible to the practice specialty of the organization being surveyed. Requests for the same specialty surveyors can be made and the AAAHC tries to honor these requests.

• The on-site survey includes a comprehensive assessment of compliance of the entire organization with the accreditation association standards, including any separate entities that have a close interrelationship with the organization seeking accreditation.

• At the conclusion of the on-site survey, surveyors hold a summation conference at which they present their findings to the organization's representatives. The organization will have the opportunity to comment on the findings, as well as the entire survey process.

Accreditation process overview

The JCAHO accreditation process seeks to help organizations identify and correct problems and to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and the quality of care, treatment, and services.

Survey process

A survey is designed to be individualized to each organization, to be consistent, and to support the organization's efforts to improve performance. During an accreditation survey, the JCAHO evaluates an organization's performance of functions and processes aimed at continuously improving patient outcomes. This assessment is accomplished through evaluating an organization's compliance with the applicable standards in the manual, based on the following:

• Tracing the care delivered to patients

• Verbal and written information provided to JCAHO

• On-site observations and interviews by JCAHO surveyors

• Documents provided by the organization.

JCAHO surveys are unannounced, with a few exceptions, such as with the Bureau of Prisons or Department of Defense facilities. An organization can have an unannounced survey between 18 and 39 months after its previous full survey. For example, an organization that is due to have its next unannounced survey in January 2010 could have its survey as early as July 2008, or as late as April 2010 (18–39 months). Data from the Priority Focus Process will determine the timing of an organization's survey within the 18- and 39-month timeframe.