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Accrediting a surgery center is considered voluntary, but an overwhelming number of surgeons find it to be an essential safeguard that lets them sleep better at night. Accreditation can result in better emergency preparedness, more effective infection-control procedures, superior fire safety, and even better business practices in general than there would have been otherwise. Just knowing that systems are in place to handle an emergency brings peace of mind to a busy surgeon and his or her medical staff.

An ambulatory facility can be a part of a surgeon’s office, a surgical suite adjacent to the office, or a separate surgical facility. The American Society of Plastic Surgeons and the American Society of Aesthetic Plastic Surgeons mandate that their members’ office-based surgical facilities be ac­credited. The accreditation process is viewed as a risk-reduction activity.

Timothy J. Marten, MD, FACS, founder and director of the Marten Clinic of Plastic Surgery in San Francisco, says, “Accreditation has been a great thing for patients and for us. It has increased patient safety and provides a framework for my staff to work in an efficient and well-organized fashion.”

Going through the accreditation process also encourages staff to work as a team and to think about systems and patient flow in a more comprehensive way. “The nursing staff learns everything they need to know about the policies and procedures they must have in place, and it helps the offices conform with compliance programs, [Health Insurance Portability and Accountability Act of 1996] privacy regulations, and [Occupational Safety and Health Administration] requirements,” says Fran McGibbon, a nurse practitioner in Great Neck, NY. “The staff gains a sense of accomplishment knowing that patients are getting the best care they can give them.”

Although the paperwork and protocols may seem daunting, the accreditation requirements for each facility are pretty much the same—whether it is a multispecialty, large-group, or single-physician practice. One red flag noted by the governing bodies is the absence of a full-time, on-site medical director. To qualify, the medical director must be board certified, practice in the same surgical specialty, and be actively involved in the day-to-day management of the facility.

James A. Yates, MD, president of the American Association for Accreditation of Ambulatory Surgery Facilities Inc (AAAASF), says, “Facilities either pass or fail and do not receive accreditation until they comply with every standard. Our standards are very straightforward and not open to much interpretation.”

Questions and Answers

Do you wish to accredit your facility? If so, the first step is for you to educate yourself about the process, its costs, and its value in the plastic surgery marketplace. Read on for common questions and answers.

What does accreditation govern?

Every facility must meet certain basic standards, and each individual governing body has its own specific requirements that every facility must meet. Some categories of standards are:

 1) general facility;

 2) operating-room (OR) policies and procedures;

 3) recovery-room policies and procedures;

 4) safety precautions;

 5) blood and medications;

 6) medical records;

 7) quality assessment;

 8) quality improvement;

 9) personnel; and

10) anesthesia.

Your procedure mix will determine the applicable guidelines for your OR. The American Institute of Architects’ regulations classify ORs as Class A, B, or C, based on the type of anesthesia used:

Class A is the least restrictive; it is used when local anesthesia is administered in procedure rooms.

Class B covers rooms in which conscious sedation is administered.

Class C is reserved for general anesthesia, requires the largest room, and has the most restrictive guidelines.

What does accreditation cost? 

The high start-up costs and administrative time involved with accreditation can sometimes be a barrier for smaller surgery centers or solo practitioners. It definitely increases staff workload, and it often requires additional part-time and full-time medical and administrative staff just for continuous documentation maintenance. The hardest part is setting up the systems and protocols. Once in place, they are relatively easy to manage.

Fees beyond the application and accreditation processes may include a resurvey fee and the cost of an outside consultant. It may be helpful to hire a consultant to walk through your facility and determine which areas and procedures need to be improved, and to train your staff about the guidelines for setting up the required documentation.

It is less expensive to build your surgery center according to code from the very beginning rather than to retrofit it later. If you build a center from the ground up, the start-up costs will be substantial. If you redesign an existing center, you may be able to minimize at least some of your expenditures, but unexpected or hidden costs may come up along the way.

The accreditation-application process is extensive and time-consuming, and it may take several years to complete. According to the AAAASF, once your application has been submitted and your floor plan has been approved, an inspector can usually be secured to evaluate your facility within 30 days.

What are the approximate fees? 

AAAASF survey fees vary depending on the facility’s type, size, range of services, and number of applicable standards. They may range from $4,000 for a small, single-specialty center to $11,000 for a multiple-OR facility.

Number of Accredited Facilities
The following are the total number of facilities accredited by these governing bodies:

• JCAHO—15,000 total facilities;
1,200 ambulatory care
• AAAHC—2,200 facilities
• AAAASF—1,000 facilities

Accreditation Association for Am­bulatory Health Care (AAAHC) fees are based on the number of surgeons and specialties and the type of anesthesia administered. They may range from $2,000 for a small facility offering local anesthesia to approximately $11,000 for a facility with 10 or more surgeons and three or more specialties that administers general anesthesia. There is an additional fee for Medicare “deemed status.”

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) fees vary depending on the number and type of patient visits and the number of additional sites. They may range from approximately $8,000 for a center that performs fewer than 5,000 procedures per year at one site to $12,000 for a center that performs 7,500 procedures per year with one additional site.

How is the accreditation process begun? 

Most surgeons will find it much easier and more cost-efficient to work with a team of experts who have gone through the accreditation process for surgery centers before, and preferably in your state. (Regulations can vary from state to state.) Assembling the right team—usually an architect, engineer, contractor, lawyer, interior designer, and consultant—and getting them involved as early as possible can help reduce the time it takes to get up and running.

Before hiring a general contractor or an architect, check their credentials with the state and find out if any complaints have been filed against them. Talk to former clients and get references. It is also a good idea to visit other medical offices and surgery centers they have worked on to see the scope and quality of their work.

Geography often presents unique obstacles. Sydney R. Coleman, MD, of Tribeca Plastic Surgery in New York City, says, “The challenges of building an accredited surgical suite in Manhattan exceeded my wildest expectations. I thought that finding the appropriate space in New York would be the most difficult task. However, looking at more than 100 spaces over 4 years and dealing with the realtors and banks was a breeze compared to the years of delays and extra expenses that followed.

“Overt lies about the cost of a project and the time to completion are part of the normal way of doing business among architects, contractors and engineers,” he continues. “The physician is foisted into a system designed to extract much more money than is represented in the initial cost estimates.”

How valuable is accreditation in the plastic surgery marketplace? 

Among consumers and the media, there is an obvious marketing value to having an accredited surgical facility that, if used to its fullest extent, has the potential to offset the costs. Being accredited by one of the leading organizations sends the message to your patients that you have made a commitment to the safety and quality of the care you offer. In this crowded marketplace, it is an excellent way to distinguish your practice as a center of excellence.

For example, JCAHO offers accredited members a publicity kit to help them promote their facility, along with a “Gold Seal of Approval™” logo that may be used as part of a consumer-outreach program. Mark Forstneger, JCAHO spokesman, says, “We encourage our accredited organizations to use the Gold Seal. Examples [of placements] include their business cards, letterhead, lapel pins, vehicles, external signage, Web site, and print advertising. The Gold Seal is an important guidepost for consumers to look for when selecting health care services.”

Interested in more information about
the accreditation process?
These Web sites are good resources.

To increase consumer awareness, your center’s Web site should also be listed on the Web site of the organization that has accredited your facility. For example, the official Web sites for the AAAHC and the AAAASF include search features that prospective patients can use to locate accredited organizations within their specific geographic region or find out if their surgeon’s center is accredited.

The topic of “ambulatory” anesthesia also raises many concerns among consumers. Accreditation assuages those fears. Each accrediting body has strict guidelines for how anesthesia services may be provided and supervised. These give the patient an added feeling of safety knowing that qualified and licensed individuals will be administering their anesthesia in a controlled setting; appropriate, well-maintained equipment will be used; and built-in precautions for emergencies are in place.

Many private insurance carriers also recognize accreditation for reimbursement of covered procedures, which may  enhance the value of accreditation to your facility.

Will accreditation become more mandated in the future? 

A vast majority of ambulatory surgical facilities in the United States remain unaccredited and operate independent from any peer-review and inspection process. An increasing number of states and medical societies are beginning to recognize the growing need to mandate the accreditation process.

“We are noting ever-increasing numbers of states that are imposing regulatory guidelines and legislation relative to office-based and ambulatory surgical facilities in general—many of them demanding a requirement for accreditation. People are willing to make changes as necessary, not because they see the light but because they feel the heat,” Yates says. If you practice in a state that is tightening its restrictions on office-based surgery, preparing for accreditation now may help ensure your future success.

“Accreditation should be a minimum standard by which we practice,” Marten adds. “The top practices will seek to not just meet, but exceed accreditation standards. I recommend that surgeons embrace accreditation, rather than avoid it.” PSP

Wendy Lewis is an international consultant, author of America’s Cosmetic Doctors (Castle Connolly), and editorial director for MDPublish.com, a medical marketing and publishing group.

Benefits of Office-Based Surgery

The main advantages of offering office-based ambulatory surgery are patient preference, convenience for the surgeons, more control over patient care, and greater flexibility of operating-room times. Patients prefer office-based surgery because they may perceive it to be less frightening than a hospital or outpatient surgery center; and generally, the costs in an ambulatory facility are lower than in a hospital. Patients are already familiar with your office and your staff, and may feel more comfortable with a friendly, service-oriented environment where they can receive more individualized care than in a larger facility. Office-based surgery also allows surgeons to consolidate their practice in one location, which can cut down on travel time and expenses. An efficiently managed office-based facility can also be a profit center for the surgeon.