Accreditation Counseling

Accreditation can be a time-consuming and tedious project for any ambulatory surgery center [ASC] or office-based surgical facility [OBSF]. Our accreditation counseling specialists are former or current accreditation surveyors for the major accrediting organizations, including the AAAHC, AAAASF and JCAHO. They know exactly what needs to be done to meet applicable accreditation standards, and years of accreditation experience allow us to accomplish it in an efficient and thorough manner. As of early 2007, 100% of our accreditation clients have successfully achieved accreditation.

Somnia views accreditation as a continuous process and the task of achieving accreditation as an opportunity to create and improve patient care habits through the development and implementation of surgical, facility and anesthesia service policies, procedures and protocols. Somnia gets involved and stays involved throughout the accreditation process and provides ongoing accreditation counseling, support and assistance for years after.

New York State Information on Office Based Accreditation

Accredidation Counseling Services

• Consultative accreditation advice on the most appropriate type of accreditation—whether JCAHO, AAAHC and AAAASF
• Accreditation counseling on the most realistic level of accreditation
• Thorough surgery center or office-based surgical facility site inspection and evaluation
• Preparation of accreditation-specific compliance checklists
• Completion of the accreditation application
• Education of staff on quality improvement and OSHA regulations
• Conducting mock surveys and progress evaluations
• Ensure ongoing TQM maintenance and compliance
• Providing specific and detailed feedback on anesthesia services
• Helping to secure ancillary service contracts such as linen, hazardous waste, biomedical, and emergency transport.

In addition to the services listed above, our accreditation counseling services and consultants will develop policies and procedures in the following areas:

• Governance
• Administration
• Infection control
• Risk Management
• Medication Management
• Medical Records & HIPPA compliance
• Personnel
• Anesthesia Services
• Anesthesia Logistics
• Quality Assurance & Improvement
• OSHA

What is Accreditation?

Accreditation is a voluntary process that enables a medical practice or ambulatory surgery center to measure the quality of its services and performance against nationally recognized standards. The accreditation process involves self-assessment, as well as a thorough review by an accreditation surveyor. Accreditation is a symbol of high quality health care and dedication to patient safety.

Top Accreditation Organizations?

There are three main organizations that accredit office-based surgical facilities and ambulatory surgery centers:

1. Accreditation Association for Ambulatory Health Care (AAAHC)
2. American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF)
3. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Do I Need to Get Accredited?

Many states are enacting guidelines or regulations that center on accreditation and those that have remained silent are likely to follow the lead of these more proactive states.

States that have been particularly aggressive in establishing guidelines based on accreditation standards or guidelines include New Jersey, Connecticut, Pennsylvania, California, Illinois, and Florida. Many professional societies are also weighing in, New Jersey, Connecticut, Pennsylvania, California, Illinois, and Florida. Many professional societies are also weighing in, including the American Medical Association (AMA), The American Society of Anesthesiologists (ASA) and the American Society for Aesthetic Plastic Surgery (ASAPS).

How Does Accreditation Differ from Licensure and Certification?

While accreditation is based upon performance improvement overseen by private organizations, licensure and certification are state-mandated and overseen by governmental entities. Accreditation focuses on achievable standards, while licensure and certification define minimum expectations. It is important to note that you can still be accredited without being licensed or certified, and vice versa.

Accreditation for My Practice or ASC?

Having your operating room or surgery center accredited has five major advantages:

1. Accreditation is a quality seal of approval by an outside agency.
2. Accreditation is a useful marketing tool and can distinguish you from non-accredited competitors.
3. Accreditation may help you obtain facility fees or enhanced professional fees from certain payers.
4. Accreditation alerts fearful patients that quality benchmarks and safeguards are in place.
5. Accreditation may help reduce the liability risk in the event of an adverse outcome.
6. Some states are now requiring accreditation.

As each facility is different, the total accreditation process can take anywhere from a few months to over a year. After completing the accreditation application and bringing your facility up to accreditation standards, it can take anywhere from 30 days to 4 months before you receive a facility inspection, depending on the accrediting organization. This timeline is a general guide since foreseen and unforeseen deficiencies with core services can cause delays. For instance, anesthesia services can be up to par or fall well short in terms of anesthesia provider census, anesthesiaprovider skill, the breadth and depth of anesthesia services and anesthesia logistics.

Do I need to also worry about the anesthesia services?

Your anesthesia service can make or break an accreditation survey. Somnia has helped anesthesia practices achieve accreditation and has a broad and deep appreciation for the role of anesthesia services in the accreditation process. Does the anesthesia service provider credential their anesthesia providers? Does the anesthesia service provider perform background checks? Does the anesthesia service provider have an anesthesia quality program or a way to collect anesthesia patient satisfaction data? Does your anesthesia service provider properly record preoperative, intra-operative or post operative anesthesia services? One of the main reasons facilities fall short of achieving accreditation is because the anesthesia service provider is unfamiliar with accreditation standards pertaining to anesthesia services, or fails to appreciate the importance accreditation organizations place on an anesthesia service.

Whether you are already in the development process or just thinking about it, Somnia can help. We are happy to answer any questions you may have about our accreditation counseling process. Please call us toll free at 1.877.4SOMNIA (877.476.6642), ext. 3541 or through email at srishaq@somniainc.com.