By Patrick Horine
When considering a purchase for your OR suite, most organizations follow a process of due diligence to investigate the benefits and risks of available options. Even when the decision resides with a designated administrative leader, those who will use the equipment are usually engaged at some level in an evaluative process. The most cursory “comparison shopping” is designed to ensure that your investment will produce a return – in greater efficiency, increased throughput, or improved safety, for example.
Are you applying that same degree of purposeful analysis to other purchases that impact your surgical setting? Whether seeking initial accreditation, considering switching to a new accreditation organization (AO), or preparing for a renewal, you owe it to your team and your organization to make sure it’s an informed decision. Due diligence applied to your process can maximize the benefit of this significant investment.
By definition, an accreditation organization with “deemed status” is an independent third party that has been given authority and responsibility by the Centers for Medicare and Medicaid Services (CMS) to ensure that patients are safe while in the care of a specific provider or supplier organization. Accreditation is validation that a health care organization meets a range of requirements for processes that correlate with improving the quality of care it delivers to its patients.
Health care is a relationship business. The relationship between health care organizations and their AO often has been characterized as adverse, controversial or combative. But just as your organization seeks to foster a positive relationship with patients, you should expect the same from your AO. Research related to accreditation outcomes suggests the relationship with the accrediting organization is foundational to achieving coherence, organizational buy-in and organizational action for effective performance.
What you should consider
From the administrative point of view, key details to research when choosing an AO would include confirming deeming authority, identifying what to expect from the survey, and comparing cost, plus evaluation of reputation and available support for initial accreditation or transition. Front line employees may have additional concerns such as accessibility and responsiveness to questions, guidance in interpreting standards and availability of resources.
As an employer, you look for soft skills in your staff in addition to clinical experience. High patient satisfaction is largely a result of their individual interactions with staff across multiple encounters and differing roles. Similar soft skills from your AO elicit greater satisfaction and more value for your teams. You may want to investigate whether an AO is collaborative as shown through an approach attitude, accessible staff and timely responses. Does it build confidence in your team through accurate information and relevant clinical and administrative expertise? Does it demonstrate flexibility and partnership by showing authentic interest in what makes your organization unique? And, in general, does the relationship foster trust across all levels of your organization?
For most organizations, three years pass between on-site surveys. This can lead to a habit of performing a just-in-time ramp up which stresses “passing the survey” as the ultimate goal. Not to imply this is the case for every organization, but some organizations may go through the triennial exercise of signaling compliance rather than committing to an ongoing process of continuous self-evaluation and improvement. This makes for stressful surveys and little lasting benefit.
Because it is imperative to the sustainability of your organization that accreditation be maintained, a continuing rather than intermittent relationship with the AO and the standards better supports quality and adds value.
To ensure you are receiving what should be expected from the relationship with your accreditation organization, transitioning and renewing ambulatory surgery centers and hospitals may want to step back and question whether working with their current AO has had a positive impact and facilitated the need to promote the health, safety and best possible experience for the organization and its patients.
There are AOs that serve limited niches. Others offer more comprehensive programs and services. Getting the greatest possible value from this unique relationship depends on your effort to discern the right fit for your needs.
Patrick Horine is vice president, acute care services at Accreditation Commission for Health Care Inc. Before performing his own due diligence and joining ACHC, he was the founding president and CEO of DNV Healthcare.
