ASC success: 7 steps to prepare for an ortho certification survey

Orthopedic procedures are on the rise, particularly in the outpatient setting, where patients, providers and payers can enjoy lower costs and increased efficiency. To stand out from other facilities in the industry and demonstrate a commitment to patient safety and quality of care, many ambulatory surgery centers (ASCs) are obtaining official certification in orthopedic procedures from an accrediting organization.

While many certification programs build off accreditation and focus on specialty care, the certification standards, themselves, remain just as vigorous. It is important for facilities seeking certification in orthopedic procedures to create a robust plan and follow specific steps to ensure compliance with the requirements and avoid jeopardizing a successful outcome. Outlined below are seven key steps to help facilities plan accordingly when preparing for a certification survey.

1. Identify core leaders

The first step is to identify the core leaders appointed to direct the specialty service, which should include a medical director and a clinical resource person. If the medical director is not an orthopedic surgeon or a neurosurgeon, then one must be appointed as a physician champion for the service and be part of the core team.

Try to avoid appointing too many core leaders, and make the decisions based on the responsibilities they will shoulder, such as:

· Creating and reviewing specialty policies

· Developing and implementing nursing education

· Participating in eight Category 1 CMEs or CEUs per year

· Acting as a resource for staff, providers and patients regarding quality improvement

Not only will the core leaders manage the certification process, they will also act as resources to staff when training new competencies and best practices, while directing education and consumer engagement activities. The leaders are heavily involved in the design of the program, and must be identified before any changes can be made throughout the organization.

2. Develop a project plan

A foundational component of the certification process is to create a project plan or action plan that is continuously reviewed and updated. This plan can also be used as the basis for your quality improvement plan for the orthopedic program. Some questions to consider when developing a project plan:

· What approach will be taken to prepare?

Consider the strengths and expertise of each team member and designate a lead for each step in the readiness process.

· How will the chapters be divided?

Divide the workload across all teams by assigning specific chapters (such as gap analysis and internal audits) to the groups with the most appropriate skillset for each.

· When is the desired date of certification?

Develop a readiness timeline of actions that work toward the desired goal, and ensure all teams are aware of and on track to meet the deadline.

Through weekly progress meetings, leaders can identify completion, discuss challenges and determine or reevaluate progress towards readiness.

3. Conduct a gap analysis

Next, you can conduct a gap analysis to determine what is missing from your current processes (such as standards, policies and procedures) and the advanced certification standards. A gap analysis is used to assess an organization’s scope, readiness for certification and resources for compliance.

To determine the gap between what’s in place and the certification requirements, collect all documentation including plans, memorandums, policies, charts and records. Then conduct a step-by-step review of all documentation:

· Read the document in detail to evaluate it against the standards

· Ensure that all findings, both compliant and not compliant, are documented

· Verify reference to current clinical practice guidelines

· If it is unclear whether the element is met or not, select NO. Selecting NO will place the element on a Plan for Improvement

Documentation of all the steps is critical. Remember, if it’s not written, it did not happen!

4. Develop a plan for improvement

The Plan for Improvement (PFI), also known as Plan of Correction, can help your organization reduce risk, provide an opportunity to teach staff and potentially identify an area for a quality improvement (QI) study to demonstrate continuous improvements. A PFI consists of six elements:

· Deficiency statement: First you need to document the Standard ID, Standard and element language as written in the handbook.

· Corrective action: State the corrective action taken immediately for each deficient practice. When there are multiple findings for one regulation, each finding must be addressed. Describe how each action, policy, procedure and training was implemented. If you were unable to correct the action, state this.

· Responsible party: Identify who will be responsible for ensuring the corrective action, policy or procedure takes place. Remember to include the committee or individual title responsible for correction plan, policy, procedure or training.

· Correction date: Ensure each corrective action, policy, procedure or training listed has a specific, documented completion date.

· Monitoring activity: During the monitoring procedure, evaluate success by ensuring that the action is effective and that the specific deficiency cited remains corrected and/or in compliance with the requirements. You need to determine:

        o The performance expectation/goal

        o The frequency of monitoring

        o Your sample and sample size

        o How you will complete your success evaluation (including tools and documentation that will be used to collect data) and frequency of monitoring

· Supporting documentation: Upload evidence of compliance for each deficiency. This may be sent in the form of drafted policies, in-service records, photographs, work orders, service contracts or bids/proposals.

Again, it is important for each element in the process to be thoroughly documented so team members and surveyors know all the necessary steps have been taken.

5. Implement actions

Similar to the other steps, implementation has not officially occurred unless it is documented and communicated.

Be sure to revise documents, policies and procedures to reflect compliance, and approve all changes with any manager, executive leadership or governing body. Take the time to communicate procedural changes in a memorandum, brochure or report so all staff and clinicians understand the updates and are educated on the best practices. Once all the teams are up-to-speed, continually monitor changes for compliance.

6. Report findings

Report the findings of deficient practice and any changes that occur as a result of process improvement. Collect all documented evidence that the change occurred, and that it was properly communicated and reported. This documentation may provide evidence of compliance for an internal audit as well as during the onsite certification survey.

7.  Conduct an internal audit

The last step is to conduct an internal audit to cross verify that all documented activity is congruent with staff knowledge and observed in their practice. An internal audit focuses on verifying that your written processes are being implemented and are effective. The findings from an internal audit should then be incorporated into the PFI and put into action, with the key points reported and communicated throughout the organization.

Once you have completed these seven steps you should be ready to submit an application for orthopedic certification. These steps can also be utilized in the annual review of your organization’s compliance with the advanced orthopedic certification and will be required for the completion of an annual attestation.