Orthopaedic Certification

Transcription

1 Orthopaedic Certification Meena S. Desai, MD Troy Sparks, BSN, RN, CNOR IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION 2017 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.

2 Speaker Introduction Meena S. Desai, MD Immediate Past Board Chair of AAAHC Chair of Technical Panel Past President Society for Ambulatory Anesthesia ASA Ambulatory Care Committee Ambulatory and Orthopedic Specialty Practice of 25,000 annual patient encounters Troy Sparks, BSN, RN, CNOR Total Joint Program Coordinator for AMSURG Corporation Developed total joint implementation guide for AMSURG surgery centers Technical Panel Member Extensive background in orthopaedic surgery as a nurse and ASC administrator

3 Key Presentation Points 1. Difference between Accreditation and Certification 2. Development of Standards 3. Benefits of AAAHC Certification 4. Overview of Orthopaedic Certification 5. Customer Experience 6. Survey Process 7. Questions

4 Accreditation vs. Certification Accreditation The foundation of health care delivery Organization-wide evaluation of standards Comment on all standards Report with decision release Certification Specialty-focused Evaluation of care and outcomes for a specific specialty population Comment on deficiencies Executive summary Preliminary report at end of survey day

5 Benefits of AAAHC Certification Specialty-specific, focused on patient outcomes Promotes team cohesiveness Facilitates consistency in care Creates a systematic approach to service line delivery Drives the organization to a higher level of excellence Fosters community engagement

6 Standards Meena Desai, MD IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION 2017 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.

7 Development of Standards Technical Panel developed Multi-specialty and Multi-disciplinary Research current clinical practice guidelines Best Practices from Multi-disciplinary view Technical review Mock surveys: development phase Beta-testing: launch

8 Level of Certification Specialty Certification Procedure type: minor and partial E.g. partial joint replacement Core requirements Advanced Specialty Certification Procedure type: complex and advanced E.g. total joints / spine Additional requirements

9 Eligibility Criteria Specialty Certification Accreditation by AAAHC, or other nationally recognized accreditation organization State / CMS certification Advanced Specialty Certification Procedural Requirements Must be performing total joint and spine procedures Minimum of 10 cases prior to survey

10 Certification Framework Effective Leadership Integrated Care 7

11 1.C. Strategic Partnerships Written criteria for selecting strategic partners Annual evaluation on strategic partners Partnership with nearby hospital Written agreement Physician / provider group Privileging At least one specialty physician is privileged at both the ASC and a nearby hospital

12 2.A. Credentialed Providers Medical Director Part of the core team Board certified Written criteria for privileging Post residency proficiency requirements Cases proctored Cases peer reviewed Number of annual cases

13 3.B. Performance Measurement Performance measures Measures collected Benchmark 85% Specialty data repository Mandatory requirement Registry must have national presence Example: AJRR

14 5.A. Prescreening and Consent Prescreening criteria Established by the organization Specific elements Discussion amongst medical team Planning for discharge occurs at admission Medical record review Compliance Peer review

15 6.B. Community Engagement Written plan for community engagement Health promotion and disease management Organization partners with community to develop health promotion activities Sponsor benefits, health publications Evaluate outcomes of health promotion activities Outcomes reported to quality committee

16 Customer Experience Troy Sparks, BSN, RN, CNOR IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION 2017 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.

17 Pre and Post Survey 1. Coaching Sessions: Series of sessions available prior to survey 2. Survey: On site, one surveyor, one day survey 3. Preliminary Report: Preliminary report end of day of survey 4. Plan for Improvement: Submit within designated timeframe 5. Accreditation Committee: Review and decision 6. Decision: Decision and certificate

18 Survey Schedule 8:00 am Meet and greet 8:10 am Core Specialty leaders conduct ppt presentation on service line quality activities 8:30 am Review schedule and modify of required 9:00 am Tour of ASC, follow patient flow pre-op 12:00 pm Lunch Review Standards 4 and 5 (patient care) 12:30 pm Review Standards 1, 2, 3 and 6 (admin) Return to patient flow, post-op 4:30 pm Exit summary

19 How to Prepare 1. Obtain copy of the Standards 2. Identify core leaders to support development and implementation 3. Attend webinar / education session 4. Assign chapters to core leaders 5. Complete gap analysis 6. Develop action plan 7. Meet weekly with team to review progress 8. Keep focused on specialty-specific policies, process and data / patient outcomes

20 Advantages Specialty-specific Focus on specialty patient outcomes Created community engagement Structured and streamlined service line delivery Built team cohesiveness and drive toward higher level of excellence Differentiation

21 Continuous Assessment/Self- Attestation Continuous assessment activity is to support the organization and ensure continuous measurement of compliance with current versions of the handbook. Self Attestation Due by January 31 of each year Fillable form available on the AAAHC website

22 Certification Cycle: 3 Years Self- Attestation Submit Application At month Survey Scheduled Interim / Survey if Applicable At month 6 or 12 Staying Connected! Ask the Expert Forum Kershnar Award Boot Camps Podcasts Webinars Onsite Survey 1 day, 1 Surveyor Decision Release By Day 15 Accreditation Committee Review On Day 11 Complete PFI Day 1-10

23 General Information: FAQ s Where do I apply? Where can I obtain the Orthopaedic Handbook? 1. under Publications. 2. Through the application process

24 General Information: FAQ s How long does preparation take? What is the cost of AAAHC Orthopaedic Certification?

25 General Information: FAQ s What does Orthopaedic Certification mean for your organization? Facilitates an environment of best practice, leading to best outcomes Recognition Differentiates your organization Reassurance Adds value It s a proud accomplishment! Advertise your certification!

26 Questions Contact Us IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION 2017 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.

27 Contact Tess Poland, RN, BSN, MSN Senior Vice President, Accreditation Services Research and Development Lead Deanna Scatena, RN, BSN Certification Program Manager, Accreditation Services Development Support