By W. Patrick Davey, MD, MBA, FACP
As an AAAHC surveyor, I think of myself as a reporter. My job is to understand how an organization operates through direct observation of how the stated policies and procedures correspond with what is actually going on in the day-to-day life of the organization. Then I work to align these observations with the AAAHC Standards in order to create an accurate description for review by the AAAHC accreditation committee.
Before a surveyor ever meets with an organization, he or she has been through a careful selection process and a rigorous training regimen, and every two years each surveyor undergoes retraining and a privileging process not unlike what a provider at an ambulatory surgery center (ASC) or hospital experiences. Surveyor training sessions are usually held in conjunction with the AAAHC Achieving Accreditation educational seminars, which are designed to introduce organizations to the latest Standards. Often, surveyors attending the retraining program are also members of the teaching faculty at the Achieving Accreditation seminar.
Surveyors are trained to provide an educational and instructive survey, one that the facility staff can benefit from as a learning experience. The surveyor is a volunteer who has frequently faced the same problems as the organization, which means he or she brings a deep understanding to the process. Once the survey has been performed, the surveyor writes up an organization evaluation that reads as friendly, informative, and helpful.
AAAHC Surveyors adhere to a strict Behavioral Code and their judgments should be based on sound medical and administrative principles. He or she will refrain from expressing personal opinions that are not related to the AAAHC Standards. Your surveyor(s) may consult on solutions to problems that do not directly relate to the AAAHC Standards. In fact, we welcome this kind of collaborative dialogue with the organizations we visit. However, if the surveyor is a consultant, he or she may not offer his or her services to a surveyed organization.
For a non-deemed status survey the surveyor will contact the organization a week prior to the survey to find out if there are specific areas of concern. For a Medicare deemed status survey, there are additional compliance standards that need to be scored according to CMS national standards and to state-specific standards.
The surveyor’s arrival is your deadline. This is the date by which your organization should have read and implemented the AAAHC Standards and organized your policies and procedures. Since the surveyor has a limited time to get a picture of your organization’s life, documentation is critical to a smooth survey. Before your survey team arrives, each surveyor will have reviewed the PreSurvey Materials but the surveyor(s) may ask for any needed additional documentation during the survey.
The day begins with an initial morning meeting. This is your chance to orient the surveyor to how your facility works. He or she will also listen and respond to any particular concerns you may have about the survey process.
Surveyors usually spend considerable time on chapters that are particularly challenging for many organizations. Chapter 5, Quality Management and Improvement, for example, is particularly important and sometimes difficult. The surveyor(s) will discuss your quality improvement process and studies with you in some detail, since AAAHC wants surveyed organizations to use quality improvement studies as a means to continuously improve clinical and administrative processes, to evaluate cost of care and to achieve better patient outcomes.
Chapter 2, Governance, is also a key focus in an AAAHC accreditation survey. The credentialing and privileging section is a particular point of emphasis. Chapter 7, Patient Safety and Infection, is another area of concern. Nationally recognized experts in these topics provide all AAAHC surveyors with extensive training in all these areas.
At the end of the first day, there is an evening’s worth of work for the surveyor to complete for the survey so we always appreciate thoughtfulness on the part of the facility staff of our time constraints. Surveyors have four days in which to complete and submit the survey report to AAAHC for staff review and voting by the AAAHC accreditation committee that makes the accreditation decision.
Within ten days of the survey, your contact person will be called and asked to participate in an evaluation of your surveyor and the survey process. This call comes from an independent agency that is not a part of AAAHC and the evaluation does not in any way affect the survey decision. Instead, the information collected is used by AAAHC as part of its own quality improvement effort.
AAAHC Surveyors treat all information obtained during the survey as strictly confidential. We will not ask for permission to copy any of your documents or other materials, and we will sign a HIPAA vendor agreement with your organization.
I enjoy my role as a surveyor and I hope that the organizations I survey enjoy the experience as well. It’s a rewarding educational experience for both of us.
W. Patrick Davey, MD, MBA, FACP practices surgical dermatology in Scottsdale, Arizona. He has been an AAAHC surveyor since 1996. Dr. Davey serves on the AAAHC Board of Directors, representing the American Academy of Dermatology. He is past chairman of the AAAHC Surveyor Training and Education Committee and currently is Vice-Chairman on the Accreditation Committee. He is also on the AAAHC Institute for Quality Improvement Board of Directors.