FEATURE
pliance. “Take peer review. People think of it as needing to get their doc- tors to review charts of other doctors. That is just one place to get infor- mation. You should also get it from satisfaction surveys, outcomes mea- surements and incident tracking.” When going through the appointment process, an ASC employee needs to request information from other peo- ple, but much of the information they should use is information their ASC should already be capturing, he adds.
Gathering and Keeping Current with Documentation At Outpatient Surgery Center of Hil- ton Head, compliance centers largely around ensuring the ASC collects accu- rate documentation on its practitio- ners that is confirmed via multisource verification, Rehill says. Sources used for background checks include the National Practitioner Data Bank and the Office of Inspector General's Exclusions Program. The ASC also verifies certifications on federal and state levels and accesses state medical boards and the National Student Clear- inghouse. “Comprehensive screenings of all practitioners protect not only our patients but also our staff,” she says. To help manage its practitioners' documents, such as medical licenses, Drug Enforcement Administration cer- tificates and insurance certificates, the medical staff office for Athens Ortho- pedic Clinic's ASCs use credentialing software. “This software allows us to set alarms to remind us in advance of when we need to update expiring doc- uments,” Vinson says. “The software also informs us of upcoming reap- pointments so that we can comply with our policy and procedure manual by sending out the paperwork 90 days prior to reappointment.” If your ASC is struggling to keep up with credentialing, privileging and peer review, electronic solutions can make a big difference, Riegle says.
Regardless of whether you use paper or automated processes for managing
credentialing, privileging
and peer review documentation, stay- ing atop deadlines is essential. “Com- pleted files must be approved by the governing board and those typically only meet quarterly,” Riegle says. “Appointments and credentials expire, so you will want to get those done far enough in advance to have them approved on time. The key is to make credentialing,
privileging and peer
review a routine. Do things on a regu- larly scheduled basis and you should not need to worry as much about expi- rations or rushing to get work done.”
Focus on Communication and Coordination Paramount to compliance success are clear lines of communication and coor- dination between stakeholders, Rehill says. Within her ASC, that largely involves the credentialing coordinator, medical director and medical execu- tive committee. Good communication and coordi-
nation with external stakeholders are pivotal as well. For example, Athens Orthopedic Clinic's ASCs are con- tracted with an anesthesia group. Vin- son has developed a close relation- ship with a member of the anesthesia group's office staff who provides ini- tial and reappointment paperwork. Despite having never met, Vin- son knows she can always reach out
to this person with any questions and ask for the information and assistance she needs. “This helps with identifying and addressing potential developments before they become potential prob- lems,” she says.
Even with good communication,
one of the most difficult steps for ASCs to complete tends to be peer review, Riegle says. “Knowing what you need to do is one thing. Getting your physi- cians to do it is another." His advice: Make participation as easy as possible. “Prepare the forms for them so they only need to answer the questions,” Riegle says. “Keep forms as short as possible with concise, easy-to-com- plete questions. Make your physicians feel part of the accreditation process by updating them on how you do and cred- iting them for their part in the success- ful survey.”
Another aspect of peer review that
sometimes contributes to deficiencies concerns the defining of "peer,” Riegle says. "For peer review, a surgeon's peer is not just another surgeon. A sur- geon should be reviewing a surgeon from the same specialty. If your ASC has just one surgeon in a specialty, look outside of your facility to find a peer in this specialty.” To help Athens Orthopedic Clinic's
ASCs avoid deficiencies, Vinson peri- odically completes an internal creden- tialing audit. Files for the ASCs' privi- leged physicians, anesthesia providers, certified registered nurse anesthetists and surgical technicians are randomly selected and reviewed. "I go through the credentialing files as if I had never seen them before," Vinson says. "I am checking to make sure what needs to be there is there and flagging anything that may have been overlooked so it can be corrected, such as documentation that a provider was reappointed at a hospital they have privileges at. We want to ensure that our healthcare providers are properly authorized to provide quality care to our patients.”
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