against AAAHC standards and its own policies, processes and outcomes by a third-party expert.


‘Meeting the Intent’


AAAHC policies and procedures in the Accreditation Handbook for Ambu- latory Health Care have long included language that explains that the stan- dards are written to be broadly appli- cable and emphasizes our concern that organizations meet the intent of each individual standard. Beginning with the 2018 edition, we are going to begin doing the obvi- ous: defining that intent. This means that for ASCs that do not participate in the Medicare Deemed Status program, the standards to be released this fall will look a little different. Each stan- dard is now redrafted to include “ele- ments of compliance” that reflect dis- crete decision points. These will be the guidelines that a surveyor will use to assess how fully an organization meets the intent of the standard. For example, Chapter 1, Patient


Rights


and Responsibilities, intends to emphasize patient-centeredness as essential to an accreditable organization. For 2017, the very first standard reads:


1.A Patients are treated with res- pect, consideration, and dignity.


The following standards, 1.B-E,


have to do with personal privacy, effec- tive communication, patient engage- ment and empowerment. For 2018, 1.A has not changed, but standards 1.B, C, D and E will become the “elements of compliance” that dive into describing our intended meaning of “respect, consideration, and dignity.” Similarly, standards that previ-


ously included more than one deci- sion point have been edited to separate each of these into a distinct element. For example, 2017 Standard 2.II.B.4, which concerns confirmation of a pro- vider applicant’s credentials using pri- mary or secondary source verification,


has been reduced from a lengthy para- graph to a more concise:


Upon receipt of a completed and signed initial application, primary or secondary source verification of credentials is conducted in accor- dance with the organization’s writ- ten procedures for credentialing.


And the corresponding elements of compliance are clear:


1. Written procedures are present. 2. Credentials are verified using pri- mary and/or secondary sources.


Rating Options Changing To date, AAAHC has used the rating options of SC (substantially compli- ant), PC (partially compliant), NC (non- compliant) or NA (not applicable). Most organizations seeking accredita- tion would perform self-assessments using this scale and on-site surveyors would identify levels of alignment with the standards in the same way. Beginning in 2018, the rating options will be revised. In the Accred- itation Handbook, after each standard, a chart defines what “fully,” “substan- tially,” “partially,” “minimally” and “non-compliant” mean relative to the number of elements of compliance for that standard. We have been using this rating methodology for our health plan accreditation program since


2012 where it has proven to increase clarity and transparency. We believe that our ASC and other organizations will appreciate that their self-assess- ments should closely mirror the sur- veyor assessment.


Accreditation is many things to


many organizations. It is a way to inte- grate Centers for Medicare & Medicaid Services (CMS) certification review with a peer-based survey against addi- tional ASC-focused criteria; it is a tool to drive quality improvement; it is a gut-check for aligning the busi- ness of health care with the art and sci- ence of medical and surgical practice; it is those fresh eyes that really see the policies and procedures that define the standard of care in your ASC. We appreciate the partnership of our accredited organizations in help- ing us see opportunities for clarity and improved communication and hope to return the favor. And the next time you pick up one of our publications or products, you will know who you are dealing with: AAAHC.


Angela FitzSimmons is the director of mar- keting and communications at the Accred- itation Association for Ambulatory Health Care (AAAHC) in Skokie, Illinois. Write her at afitzsimmons@aaahc.org.


ASC FOCUS SEPTEMBER 2017 |www.ascfocus.org 9


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30