SDS Accreditation Update

Strategic plan necessary for accreditation success

Accrediting agencies do not provide a blueprint for writing a strategic plan. However, The Joint Commission and Accreditation Association for Ambulatory Health Care (AAAHC) expect hospital, ambulatory surgery center (ASC), and office-based surgery administrators to devote time to planning.

"Strategic plans vary from organization to organization. We try not to be prescriptive and say they must have a planning document that includes the following elements," says Marshall Baker, MS, FACMPE, immediate past president of AAAHC.

To determine if administrators have conducted long-range planning, a surveyor most likely would read the minutes of board meetings and the planning document, he adds. The surveyor wants to see that the organization dedicated time to determining where it is going, why it is going there, and how it is getting there, explains Baker.

It is meaningless to read in governing body minutes that states an organization talked about plans for the upcoming year. Organizations must commit those plans to writing, but the document can be as simple as a one-page bullet outline with areas broken into headings, such as staffing and services, says Baker.

While solo providers might carry the strategic plan around in their heads, that information is not enough, says Marsha Wallander, assistant director of accreditation services at AAAHC. There must be some sort of brief document outlining the strategic plans for the next 3-5 years, which might include adding another physician or expanding to a second procedure room.

The Joint Commission surveyors would not ask per se whether an ASC has a strategic plan. However it can be used to illustrate compliance with the leadership chapter, according to Michael Kulczycki, the executive director of the Ambulatory Care Accreditation Program.

AAAHC surveyors want to see that administrators dedicated time to planning and did not just give it lip service. For example, did they make an effort to forecast the future by researching what the future holds for Medicare reimbursements? Or was an analysis of medical staffing completed to determine if any high-volume surgeons might be retiring or leaving?

At least quarterly, have the strategic plan review on the agenda, because the AAAHC administrative standards require management to follow the strategic plan of the organization, says Baker. In that way, goals can be evaluated. For example, if the goal was to be in three managed care plans by the end of the first quarter but the ASC is only in one, administrators need to determine what prevented them from reaching the goal.

"Strategic planning is a serious activity, a necessary activity, and it is essential to the success of the organization," says Baker.