By Patrick Horine, MHA
Accreditation offers benefits far beyond reimbursement-driven compliance. ACHC has shared valuable insights and best practices in previous articles, demonstrating the significant benefits an accreditation organization can bring to your work in the OR. We value our connection with staff focused on surgical services and we are dedicated to being a consistent resource for you.
Across articles from our acute care services team members, we’ve emphasized the ACHC approach to accreditation by looking beyond the standards to assist organizations with meaningful, action-oriented guidance. Some may view accreditation as a strict set of black and white rules, but it’s crucial to recognize the shades in between that represent different avenues for achieving compliance that may yield better results for your team and your patients. And that’s how ACHC works.
For the surgical environment, whether in hospitals or ASCs, we’ve used OR Today as a forum to provide examples, insights, and recommended solutions to ensure compliance with standards while enhancing performance under the unique conditions of a procedural setting.
Using QAPI to Build a Culture of Safety
One example of such a solution is the development of a robust quality program that includes the use of data and root cause analysis to identify underlying issues (see July 2024). While RCA is often used to investigate adverse events, it can also address process improvements, staff education needs, and updates needed for policies and procedures.
In the surgical setting, patient safety involves numerous risks that must be carefully managed. Cultivating a proactive culture of safety is essential. This requires coordinated efforts and standardization to reduce confusion/promote consistency among team members involved in patient care. A key focus has been the pre-anesthesia evaluation, a process familiar to most hospitals and ASCs (see April 2024). Organizations that adopt a standardized approach to this evaluation can more effectively manage risks for both patients and staff. It’s not just a procedural requirement; the anesthesia team must actively engage with the findings from their assessments. Adhering to these standards is vital for ensuring safe delivery of services and enhancing overall outcomes of care.
One growing concern in the surgical setting is the risk of surgical site infection (SSI). As highlighted in an April 2023 article, a result of SSI is increased scrutiny of infection prevention practices during accreditation surveys. Implementing best practices upfront effectively mitigates this risk.
Surgical services share responsibility for the organization’s infection prevention and control program with the entire organization. This involves conducting risk assessments, adopting nationally recognized guidelines, and developing robust policies and procedures. A strong culture of patient safety includes monitoring SSI prevalence and digging deeper to understand the underlying causes of these infections.
Assessing and Addressing Environmental Risk
It is crucial for surgical teams to remain vigilant, ensuring that infection prevention practices are consistently implemented in the surgical environment. Taking proactive steps to identify and address potential risks can significantly enhance patient safety.
The physical environment is a common source of risk within surgical settings. As organizations expand their surgical offerings, our expert on the physical environment and life safety has written about how important it is for leaders to grasp the risks tied to new construction or renovation (January 2024). Risk assessments are key in this context; they should evaluate not only the surgical area but also adjacent spaces.
Utilities, airflow, infection prevention, external influences, and other hazards are all factors to be weighed and considered. While accreditation standards provide a baseline, going beyond these requirements is vital. Thorough risk assessments should involve regular collaboration between surgical services leaders, staff, infection preventionists, and facilities teams to ensure a safe environment for patients and staff.
Trust Through Accountability
Addressing compliance, employing best practices, and ensuring consistent processes are the baseline for a safe environment and quality care. A strong relationship with your accreditation organization (AO) takes it a step beyond to foster internal trust through accountability and respect for the accreditation process. For a health care organization to thrive, accreditation should represent more than a survey event that occurs every three years. Nurturing the relationship with your AO should extend beyond survey interactions. And when regular contact is positive and welcomed, the benefits accrue. Accreditation becomes a tool to educate and actively promote health and safety for the organization and its patients.
ACHC will continue to provide valuable resources for those responsible for surgical services. We appreciate OR Today as a platform to share these insights, emphasizing our shared accountability for maintaining the safest practices and environments for surgical patients and staff.
Find previous ACHC articles at https://tinyurl.com/2s4fh8uh.
– Patrick Horine, MHA, is vice president of acute care services at ACHC. Before joining ACHC, he was the founding president and CEO of DNV Healthcare.
