SDS Accreditation Update: Opening soon? Do you need an early survey?

Early options help obtain reimbursement, licenses

The construction is complete; you have your occupancy certificate; and you’re ready to start taking patients.

Unfortunately, you have no payer contracts and no license, and you can’t obtain any until you’re accredited. What are your options?

The Accreditation Association for Ambulatory Health Care (AAAHC) in Wilmette, IL, and the Joint Commission on the Accreditation of Healthcare Organizations offer the option of an early survey that can help newly opened same-day surgery programs avoid the financial hardship of the standard four- to six-month waiting period required to accumulate operational data.

"We were ready to open but needed accreditation in order to obtain payer contracts and Medicare reimbursements," says John M. Powell, chief executive officer of Orthopedic Surgery Center of the North Shore in Peabody, MA.

Because Powell’s survey included certification for Medicare deemed status, he did have to be open and have performed at least one procedure.

"We did perform a few cases for which we weren’t paid so that we would have some patient records to show the AAAHC surveyor who conducted our Early Option Survey," he says.

"The surveyor reviewed our organizational structure, our policies and procedures, our staff credentials, our few medical records, and our building," Powell explains. The Medicare component of the survey required Powell’s facility to meet the Life Safety Code 2000 Edition.

"The surveyor checked all of our fire safety equipment, our gas lines, and every aspect of the building," he says. "We knew that we needed to meet the Life Safety Code, so even though Massachusetts does not require our nitrous oxide to be vented outside, we did vent it outside because it is required for Medicare," Powell adds.

The Joint Commission also offers an early survey to newly opened same-day surgery programs, says Michael Kulczycki, executive director of business development for the association.

"We refer to it as an Early Survey Option [ESO] or Option 2, and it is very appropriate for organizations that are seeking a fast track for reimbursement reasons," he says. "We conduct about 50 ambulatory surgery or office-based surgery ESOs each year, with the majority of them being office-based," Kulczycki adds.

An early survey is conducted in two parts, with the first survey taking place before the program has had a chance to gather data to show clinical trends, quality improvement efforts, or outcomes.

"Our surveyor did want to see our written quality improvement program and a description of the studies we were starting," Powell says.

The surveyor also asked staff members to talk about quality improvement to make sure everyone understood the process and were capable of implementing the plan, he adds.

"When the surveyor returns in six months, he will look at the data we collect, the areas for opportunity we identify, and the actions we take to address problems," Powell says.

Because the early survey is conducted in two phases, it is priced higher than normal surveys, says Kulczycki.

But an organization that undergoes an early survey does obtain full three-year accreditation if the follow-up survey takes place within four months of the first survey and the program has followed through on the plan to identify and address quality improvement issues, he points out.

The date of the three-year accreditation is retroactively assigned an effective date of the day after the first survey, which is useful for reimbursement purposes, Kulczycki adds.

Tips for successful completion of an early option survey include engaging the physicians as well as all staff member in the process, Powell explains.

"It takes time to prepare all of the policies and documents that you need to demonstrate you know what it takes to comply with standards and requirements," he continues.

"The only way to complete everything is to work together," Powell adds.


For information about early option surveys, contact:

  • Michael Kulczycki, Executive Director, Business Development, Ambulatory Accreditation Program, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5290. E-mail:
  • Joan Riebock, Senior Director, Program Operations, Accreditation Association for Ambulatory Health Care, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091. Phone: (847) 853-6060. Fax: (847) 853-9028. E-mail: