accredita)on of oﬃce-based lab

OEIS 2017 Annual Meeting | March 31, 2017 | Santa Monica, CA

Accredita)on of Office-Based Lab

PeterLin,MDProfessorEmeritusofSurgery,BaylorCollegeofMedicine

UniversityVascularAssociates,LosAngeles,CA

SamAhn,MDDFWVascularGroup,Dallas,TX

UniversityVascularAssociates,LosAngeles,CA


Why seek accredita)on?


For Good Reason • MandatedbysomestatesincertainsituaGons(ie:withcertainlevelsofsedaGon)

StateswithAccredita.onRequirements

California NewJersey

ConnecGcut NewYork

Indiana Ohio

Kansas Oregon

Kentucky Pennsylvania

MassachuseSs RhodeIsland

Nevada SouthCarolina


For Good Reason

•  Itisrecognizedasasymbolofqualityforliabilityinsurancecompanies,stateandfederalagencies,andthepublic

•  EasesaccesstomanagedcarecontractsandencouragespaGentreferrals

• ManyprivateinsurancecarriersrecognizeaccreditaGonforreimbursementofcoveredprocedures


For Good Reason

•  IncreasescompeGGveedge• NaGonally-acknowledgedbenchmarkofquality

•  EffecGvelymonitorandimplementthelatestadvancesinoutpaGentcare

•  ExperiencedsurveyorsoffervaluableinsightsandcomplianceGps


How do I become accredited?


!  AAAHC•  Accreditation Association for Ambulatory Health Care

!  AAAASF•  Am. Association for Accreditation of Ambulatory Surgery Facilities

!  JointCommission


AAAHC Accredita)on Associa)on for Ambulatory Health Care

• Foundedin1979withafocusonambulatoryhealthcarefaciliGes.Currentlyaccreditsmorethan6,300organizaGons.

• AAAHCoffersaccreditaGonprogramsforambulatorysurgerycenters,office-basedsurgerycenters,primarycarepracGces,occupaGonalhealthcenters,retailclinics,healthplans/managedcareorganizaGons,studenthealthcenters,andlargemedicalanddentalgrouppracGces.

• www.aaahc.org


AAAASF Am. Associa)on for Accredita)on of Ambulatory Surgery Facili)es

• Foundedin1980,providesaccreditaGonforoutpaGentfaciliGes.Currentlyaccreditsmorethan2,000faciliGes.

• HoldsoutpaGentandoffice-basedfaciliGestohospitalstandards.

• RequiresphysicianstobeboardcerGfiedandhavehospitalprivilegesforanyproceduretheyperform.

• Requirestheuseofanesthesiaprofessionalsfordeeperlevelsofanesthesia.

• www.aaaasf.org


The Joint Commission

• Establishedin1965whentheSocialSecurityprogrammandatedhospitalaccreditaGonforMedicareandMedicaidprograms.

• ItwasoriginallynamedJointCommissiononAccreditaGonofHealthcareOrganizaGons(JCAHO).In2007,itwasrenamedastheJointCommission.

• Currentlyitaccreditsmorethan20,500healthcareorganizaGonsandprogramsintheUS,and>90%arehospitals.

• www.jointcommission.org


The Basics

• 3majoraccrediGngagencies:– JCAHO– AAAHC– AAAASF

• DeterminewhichoftheseBESTsuitsyoursekngandproviders.Thereareslightdifferencesbetweenthem!Forinstance,AAAASFrequiresthatALLprovidersareboardcerGfiedforthatspecialtyinordertoperformprocedures.


• Physiciansmusthavehospitalprivilegesforanyprocedurethatisperformedatthefacility.

• RequirestheuseofAnesthesiaprofessionalsfordeeperlevelsofanesthesia.

• Requiressafesurgicalenvironment,equipment,drugs,etc.• Requirespeerreview(peeroversight).• Complywithapplicablelocal,state,andfederalregulaGons.includinglicensure,firesafety,sanitaGonandbuildingcodes.

• AdheretofederallawsandregulaGonsaffecGngtheiroperaGonsuchasOSHAblood-bornepathogensstandards,hazardouswastestandards,theAmericanswithDisabiliGesActandHIPAA.


• ApplicaGonforaccreditaGon• CurrentStandardsManual• Physicalenvironmentrequirements• PoliciesandProcedures• Equipment&MedicaGon• CredenGaling&PersonnelRecords• Manuals&Logs


The Standards

• EachaccrediGngbodywillhavestandardstomeet• Alwaysstartwithcurrentstandardsmanual

• Standardsareaguidebookforyou• Developandimplementnewpoliciesandprocedures• Evaluatecurrentpoliciesandproceduresforadequacy

• Standardscoverbasicrequirementsofasafely-operaGngfacilitysuchasgovernance,facilityrequirements,administraGon,safety,etc.


Policies and Procedures

• AccreditaGonstandardsguideyouonwhatpoliciesandproceduresarenecessary

• Somecompaniesoffercompletepolicy&proceduremanuals;justbesuretocustomizeforyourownpracGcesekng


Watch out for…

• Havingpoliciesthatdon’tapplytoyou– AlwayscustomizepoliciesforyourpracGce

• Havingapolicyandnotabidingbyit– Reviewpoliciesatleastannually– Reviewpoliciesasissuesarise.– Incidents,complaints,etc.maypromptpolicyreview/changes

– Educate,educate,educatestaffandproviders• Untrainedstaff


The Survey

• “EarlyOpGonSurveys”canbedone,dependingonstaterequirements

• Typically1day• ExperiencedsurveyorwillprovideaconsultaGvesurvey

• DecisiontofollowsurveywithconsultaGvenotes• Usually1-3yearsbetweensurveys


Between Surveys

• BECAREFUL!It’seasyto“stop”keepingupwiththingsbetweensurveys.• Random,unannouncedsurveysareperformed!

• RecognizethevalueoftheaccreditaGondecisionandwhatitmeanstoyourpracGce;thiswillhelpyouprioriGzeaccreditaGonacGviGes

• Alwaysgetanupdateonstandardseachyear;mostaccrediGngagenciesupdatestandardsannually.

• Performperiodicself-inspecGonstoensurecompliance


Helpful Resources


Endovascular Today, Sept 2015, vol 14, #9 www.evtoday.com


Annals of Vascular Surgery, 2017 Jan;38:332-338.

www.DrPeterLin.com


Should you consider geNng OBL accredita)on?

accredita)on of oﬃce-based lab

Documents