Top 6 Fail Points During the Accreditation Survey

- August 21, 2015 -

Top 6 Fail Points During Accreditation

From physicians and nurses to health care administrators, all health care personnel become a bit nervous when it’s time for a site visit from accreditation officials. There are several organizations that provide accreditation, including the Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and American Association for Accreditation of Ambulatory Surgery Facilities  (AAAASF).

These organizations seek to uphold the same general standards, but each differs slightly in its accreditation format and specific rules. Regardless, there are several common areas in which healthcare organizations fail to receive accreditation. Carefully addressing these common fail points will ensure that you receive accreditation with no areas of deficiency.

1. Poorly managed credential files.

One of the top reasons that facilities fail to pass their accreditation inspections is credential files that have been improperly managed. A healthcare organization must provide up-to-date information about each physician working in the system. Failure to do so often results from mistakes within a homegrown credential management tool—usually a spreadsheet— that is incapable of tracking and reminding the credential manager about expiration dates. The sheer volume of documents required outweighs the system’s capabilities to efficiently support the task.

Information also becomes a challenge to locate when the physical documents are disorganized and difficult to locate within a file. It is common for credential managers to overlook important credential paperwork without cross-referencing against a checklist. As a result, the outdated documents and other missing information are ingredients for failure.

Poorly managed credential files also include those that are left to the last-minute scramble due to a reminder system failure. Hours of personnel time are lost on hunting documents instead of focusing on accurately recording and reviewing. The “paper chase” may not always end successfully.  

2. Inappropriate documentation regarding infection control.

Control of healthcare-associated infections is an enormous area of concern for all health care accreditation agencies. The Centers for Disease Control and Prevention reported that there were more than 700,000 estimated healthcare-associated infections in 2011, the last year for which data were available. With the rise of hospital-onset methicillin-resistant Staphylococcus aureus MRSA), Clostridium difficile (C. difficile), catheter-associated urinary tract infections (CAUTI), and select surgical site infections (SSI), this is a serious problem.

Your organization must have a clear, documented policy for infection control. This includes clinical staff meetings about infection control topics, including hand washing, postoperative infections, sterilization techniques, cleaning protocols, and procedures for needle sticks. Documentation of meetings must include meeting minutes about exactly what was discussed. If healthcare-associated infections have been an area of concern for your organization, there must be clear documentation of an action plan and progress toward goals.

Additionally, accreditation agencies have specific guidelines about staff members who have received formal training in infection control. For example, the AAAASF requires surgery centers to have at least one nurse who has been trained through a course offered by the Association of Perioperative Registered nurses or an equivalent.

3. Lack of a quality assurance program.

In many cases, it is simple mistakes rather than gross negligence that causes institutions to fail their accreditation. Developing a quality assurance program is essential to preventing these errors. For example, a good quality assurance program includes tracking of narcotic medications, procedures for providing patients with advanced directives, provision of a patient bill of rights, and inclusion of other relevant patient paperwork. All of these procedures should be properly documented, and there must be clear policies for instances in which guidelines were not followed. This includes a clear, stated policy for disciplinary action for employees who have made errors.

4. Failure to use best practices in patient charts and other documents.

Accreditation inspectors often use patient charts as a good indicator of the facility’s overall approach to careful, detailed work. Site inspectors can ask to see nearly any piece of documentation, including patient charts. Whether you use paper charts or an electronic medical record system, it is essential to ensure that patient records are in good order. This includes avoiding blank spaces, logging records of all patient interactions, avoiding cross-outs, and using clear, understandable language.

The same principle holds for staff records. Information about physician credentialing and licensure, staff inoculations, patient exit surveys, personnel files, continuing education (CE) documentation, and meeting minutes must be maintained in an organized system.

5. Failure to develop appropriate, actionable risk management plans.

Every healthcare facility must be able to provide risk management protocols for a variety of situations, from fires or armed intruders to patient legal suits or attorney requests for records. For emergency plans, ensure staff members have been appropriately trained and that safety drills have been conducted. Documentation of training meetings is necessary for risk management plans as well as contingency plans for things that could go wrong.

Health care administrators at your organization must also collect data about adverse events or near misses. Following these events, it is important to display evidence that staff were retrained as necessary and that the data were used to reduce the likelihood of future adverse events.

6. Ineffective policies to maintain patient confidentiality.

HIPAA guidelines regulate the privacy of identifiable health information and electronically protected health information. Individual states may have additional regulations about patient privacy. Violations may be as simple as a sign-in sheet at the front desk that allows prior patients’ names to be visible. Similarly, situations such as physicians discussing treatment with patients with only a curtain to block sound are violations of patient confidentiality.

Each healthcare organization must have a well-documented plan to maintain patient confidentiality. This includes providing patients with their HIPAA rights, training staff about inappropriate disclosures of patient information, failing to destroy outdated information, or not using appropriate encryption for electronic records.

The Bottom Line

The accreditation process is all about organization and the details. Making detailed documentation a routine part of your daily practice goes a long way in ensuring successful accreditation.

Here at Silversheet, we focus on the details to implement solutions for healthcare facilities. Learn how our paperless software can support you in the credentialing process for a successful accreditation survey.