SDS Accreditation Update

Fire drills alone won’t meet AAAHC requirement in 2005

More guidance given re: medical discharge, patient verification, and other standards

In 2004, the Wilmette, IL-based Accreditation Association for Ambulatory Health Care (AAAHC) revised standards to identify the need for specific personnel to be available until the patient was medically and physically discharged. For 2005, the AAAHC has revised the same standards, says Beverly K. Philip, MD, director of ambulatory surgery at Brigham and Women’s Hospital in Boston and chair of the AAAHC Standards and Survey Procedures Committee.

"We discovered that the requirement that the surgeon or appropriate personnel be immediately available was not clear and was interpreted differently by different people," she says. "We now state that a surgeon or dentist be present until the patient is medically discharged and that personnel who are qualified in advanced resuscitative techniques be present until the patient leaves the facility," she explains.

A revision to the Facilities and Environment Chapter includes an expanded footnote to 8-B-2c, which reinforces that the four required emergency drills per year should be appropriate to the organization’s activities and environment.

The revision related to emergency drills was to make sure organizations do more than fire drills, Philip points out.

"We heard from surveyors that organizations were interpreting the standard to mean only fire drills, and the organizations were not holding drills related to medical emergencies, tornados, earthquakes, bomb threats, or other emergencies that might pertain to them because of their location," she explains. "We want our organizations to be prepared for all emergencies, not just fires."

The Joint Commission on Accreditation of Healthcare Organizations expects organizations to conduct emergency drills in addition to fire drills, says Michael Kulczycki, executive director of business development for the Joint Commission.

Part of an organization’s management plan is an assessment of area hazards and the development of plans to address that type of emergency, he says.

"For example, if a same-day surgery program were located near a nuclear plant, the surveyor would expect to see a plan that addresses the staff’s responsibility in case of an accident at the plant," Kulczycki notes.

"In fact, if the facility is part of an overall area disaster plan and will receive victims, a drill using volunteer victims must be conducted once a year."

AAAHC has revised standards related to quality of care and patient safety, based on issues identified by the Washington, DC-based National Quality Forum.

While many of the safety issues addressed by the original and the revised standards are similar to the National Patient Safety Goals of the Joint Commission, Philip says the AAAHC requirements aren’t exactly the same. "We tailor our requirements to the realities of our organizations, she notes. "Many Joint Commission organizations are larger facilities that handle much higher volume, so their requirements will differ from ours."

One difference in the requirements is the identity of the person verifying patient identification, surgical site, and procedure. The AAAHC requirement in Chapter 10-S states that the operating surgeon is personally responsible for ensuring verification has occurred, Philip notes.

"Joint Commission requires that a designated member of the team ensure that verification has taken place," Kulczycki says. "We approach the verification process as a team effort rather than an individual responsibility," he adds.

Other AAAHC revisions include integration of the physician peer review process into the re-credentialing process and a description of the specific characteristics of a quality improvement study.

"Many of the revisions provide specific guidance in the activities that are required to meet the standards," Philip adds. "For example, many AAAHC organizations already conduct benchmark studies and quality improvement activities, but not all of them are doing it consistently," she explains.

AAAHC standards are constantly evolving based upon feedback from surveyors and accredited members, Philip adds. "These changes are necessary to keep AAAHC-accredited organizations on the cutting edge of providing quality patient care," she says.