MarkerFeb 2005 Volume 1 Number 6 spacer.gif

The Mad Dash to Accreditation
by Shannon Marie Smith, The Rush Group, LLC, San Francisco, CA

Most people have heard at least one horror story of a patient suffering at the hands of an unlicensed practitioner. With all the rules and regulations governing the industry, it's hard to imagine how someone without the proper credentials could be granted privileges. Some might hastily conclude that the facility had lax administrative processes. Possibly, but if it was an accredited facility, you have to wonder how it happened. Could it be that these facilities are on their best behavior only when the surveyor comes calling?

Fracturing a few rules

Rules are often bent and those that bend them are forgiven, sometimes even rewarded if a desirable outcome results. Case in point: A physician expresses interest in joining the medical staff. Facility administrators are delighted, and many will do whatever it takes to help the process along.

It's not uncommon for credentialing staff to complete most of the application on behalf of a new physician and to grant the new doc privileges before the process is complete. The staff might decide to supervise new physicians, particularly those practicing within the community or known by the medical staff, while their credentials are verified. Slight departures from policy such as these, however, expose even a well-run center to unnecessary risk.

Unfortunately, until something goes gravely wrong, most healthcare providers regard administrative checks and balances as a burden rather than as a safeguard. Many of you are taxed by the demands of caring for patients and simply lack the time necessary to stay on top of administrative duties.

It's not at all surprising that completing forms and evaluating staff are often a low priority for administrators.

Cram session

But things change as a facility's survey date nears, don't they? Documentation needed to demonstrate compliance with the accreditation standards becomes a top priority. Staff frantically work as the survey date gets closer and closer and in the days before, the mad dash for accreditation begins.

Surveyors use prior results and the results of other centers to focus their efforts. Credentialing files are always reviewed, but lately surveyors are spending more time reviewing the credentials of ancillary staff, and in particular those not employed by the center. It's not uncommon for credentialing staff to overlook a surgical tech brought in by a physician, especially if the physician is routinely accompanied by sales representatives. The more people allowed in the operating rooms, the harder it is for administrative staff to know who does what.

Staff competence is another area of surveyor interest. Surveyors are expecting more than just completed evaluations. They want to see evidence of improvement. That means staff need to have clearly defined and easily measured responsibilities. Specifying expectations for staff and developing meaningful job descriptions is time consuming. However, it's worth the effort. The process typically reveals ways to streamline processes and free up the resources needed to improve care.

Needless to say, keeping up with administrative tasks and changes in the standards will make the survey process a lot less stressful for all. More importantly, however, doing so reduces the risk of errors and ensures your facility has the resources necessary to deliver the highest quality of care.