Accreditation Surveys



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Indian Health Service Oral Health Program Guide


Accreditation Surveys

Accreditation is a determination by an accrediting body that an eligible healthcare organization complies with applicable standards. Indian Health Service (IHS) facilities have been directed to become accredited by one of the national accrediting organizations. The best-known of the organizations that accredit hospitals and ambulatory healthcare facilities are the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Accreditation Association for Ambulatory Health Care (AAAHC). The Centers for Medicare and Medicaid services (CMS) also accredit healthcare organizations. To date, the IHS has had few, if any, facilities undergo CMS accreditation, so no details about this process are included in this chapter.

All of the recognized accrediting agencies require certain levels of quality assessment and quality improvement activities, ongoing program evaluation, peer review, adherence to life-safety standards, and the like. Accreditation offers many more quantitative as well as intangible benefits to a healthcare organization than public recognition alone. Accreditation can actually enhance the strategic management decision-making process. According to the AAAHC, organizations that have achieved accreditation have indicated that accreditation helps them do the following:


  • Find new ways to improve the care and services they offer

  • Increase their efficiency and reduce costs

  • Develop better risk management programs

  • Lower liability insurance premiums

  • Motivate staff and instill pride and loyalty

  • Strengthen public relations and marketing efforts

  • Recruit and retain qualified professional staff members

  • Develop alliances with other provider groups such as hospitals and managed care organizations

According to the Joint Commission, several other benefits result from accreditation.

  • Identification of strengths and weaknesses with particular attention to areas in which performance may be improved

  • On-site education and consultation

  • Increased staff morale and enhanced ability to recruit staff

  • Public recognition of the organization’s commitment to quality

  • Eligibility for reimbursement by many third party payers

  • Immediate eligibility to participate in the Medicare program

  • Recognition, in most states, of compliance with state licensure requirements

Meeting the requirements of one of these organizations is a way to ensure that your clinic provides quality services in a safe and healthy environment.

The survey process for both organizations will include a walk-through of the clinic and staff interviews. It is essential that all members of the staff be aware of the policies and procedures related to day-to-day activities such as appointments, sterilization, infection control, emergency protocols and procedures, and the like. Their answers to questions about such matters must be consistent with the written policies and procedures, or deficiencies will be noted. Additionally, dental program procedures in areas such as infection control, sterilizer monitoring, etc. that have similar components elsewhere in the facility must be consistent with the policies and procedures elsewhere in the facility.

Equally important is how deficiencies are handled during the survey process. Both organizations frequently will not deduct points if a noted deficiency is rectified with a new or revised policy, procedure, or protocol before the completion of the survey. Rectification, or formal written plans for change of deficiencies that are noted in the initial clinic “walk through”, for example, can serve as an opportunity for your facility or department to make an immediate improvement. Such actions can leave a positive impression with some surveyors, as this type of rapid response by the facility exemplifies the process of cooperative learning and improvement that the accreditation organizations wish to foster during the review process.

JCAHO

Many IHS facilities that have become accredited have done so through the JCAHO, which calls their quality assessment and improvement activities “Performance Improvement” (PI). PI is a prospective way of improving how things work by ongoing monitoring, data collection and analysis, planning, implementation, and re-assessment. The details of this process, as well as some simple statistical tools for data analysis are included later in this chapter in the section titled “An In-depth Look at Quality Improvement.”

The focus of JCAHO surveys changes almost annually. Over the past several years some of the areas of focus have included the following:


  • Sentinel events

  • Root cause analysis

  • Failure mode analysis

  • Surgical site documentation (e.g., marking surgical sites)

  • Prescriptions and medication errors

  • Pain assessment and management

With the frequent changes in focus and standards, it is not possible for the OHPG to keep up with the changes and provide a detailed, step-by-step guide on how to prepare for a JCAHO survey. Rather, each dental program needs to be part of the overall survey process within the local hospital or ambulatory care center, and follow the guidelines in the most recent edition of the appropriate accreditation manual. Most facilities appoint a JCAHO coordinator when preparations for a survey begin. The dental program needs to coordinate with this person.

IHS Dental Program and JCAHO Accreditation

Even though it is difficult to predict how thoroughly a dental program will be evaluated, some historical patterns provide guidance in preparation for future surveys. While the JCAHO has no dental-specific standards, programmatic components that seem to have a higher probability of review include the following:



  • Policy and procedure manuals

  • Credentialing, privileging, and competencies of unlicensed independent practitioners

  • In-house quality improvement (pi) programs

  • Infection control protocols (must be consistent with the rest of the facility)

  • Facilities and biomedical maintenance

  • Safety procedures

  • Evidence of staff meetings and in-service training

  • Drug storage and utilization

  • Emergency drug kits

  • Nitrous oxide or sedation protocols and maintenance of equipment

  • Adequacy of documentation of the medical record for dental treatment procedures

Additionally, the dental program will likely be reviewed for its compliance with the standards governing the JCAHO’s current areas of focus, which will change from year to year. The review procedure is becoming more process and outcome oriented, and active ongoing interdepartmental quality improvement is being examined more critically.

AAAHC

An IHS or tribal program may attain accreditation through AAAHC. There are a total of 24 standards developed by AAAHC for ambulatory care centers, and several of these standards may apply to all or part of dental operations in an I/T/U facility:



  • Rights of Patients (Core Standard)

  • Governance (Core Standard)

  • Administration (Core Standard)

  • Quality of Care Provided (Core Standard)

  • Quality Management and Improvement (Core Standard)

  • Clinical Records and Health Information (Core Standard)

  • Facilities and Environment (Core Standard)

  • Anesthesia Services (Adjunct Standard)

  • Dental Services (Adjunct Standard)

  • Diagnostic Imaging Services (Adjunct Standard)

  • Teaching and Publication Activities (Adjunct Standard)

  • Research Activities (Adjunct Standard)

For more detail on these and all 24 standards, visit the AAAHC Web site at www.aaahc.org.

The AAAHC Handbook for Ambulatory Health Care does contain a chapter on Dental Services (Standard 12). This chapter was expanded considerably in the 2006 handbook, now containing 15 specific categories, or “characteristics” that an “accreditable organization” that includes the provision of dental services should have:



  1. Dental services provided or made available are appropriate to the needs of the patients.

  2. Clinical records are maintained according to the requirements found in Chapter 6, Clinical Records and Health Information, of the AAAHC Handbook.

  3. Anesthesia provided or made available shall meet the standards contained in Chapter 9, Anesthesia Services, of the AAAHC Handbook.

  4. Surgical services provided or made available shall meet the standards contained in Chapter 10, Surgical and Related Services, of the Handbook.

  5. Personnel providing dental, surgical, or anesthesia services are prepared to evaluate, stabilize, and transfer medical emergencies that may occur or arise in conjunction with services provided by the organization.

  6. Dental services are consistent with the definition of dentistry according to state regulations.

  7. Dental services performed in the facilities owned and operated by the organization are limited to those procedures that are approved by the governing body.

  8. Dental procedures are performed only by dental health professionals who are licensed to perform such procedures within the applicable state or jurisdiction; and have been granted privileges to perform those procedures by the governing body of the organization (in accordance with the Handbook, Chapter 2.11).

  9. Personnel assisting in the provision of dental services are appropriately qualified and available in sufficient numbers for the dental procedures provided.

  10. An appropriate history and physical is conducted and periodically updated, which includes an assessment of the hard and soft tissues of the mouth.

  11. The organization develops policies and procedures related to the identification, treatment and management of pain.

  12. The necessity or appropriateness of the proposed dental procedure(s), as well as alternative treatments and the order of care, have been discussed with the patient prior to delivery of services.

  13. The informed consent of the patient is obtained and incorporated into the dental record prior to the procedure(s).

  14. Imaging services provided or made available meet all the standards of Chapter 17 of the handbook and the organization has guidelines to address the type, frequency and indications for diagnostic radiographs.

  15. The organization has a mechanism in place to evaluate and monitor dental products that the organization makes available for sale to patients to ensure such practices are done in an ethical manner.

Programmatic components that are likely to receive attention during a AAAHC survey include the following:

  • Appointment system/procedures.

  • Peer review and Privileging activities for providers.

  • Nitrous oxide and sedation protocols.

  • Instrument sterilization, including sterilizer monitoring, instrument storage.

  • Ensure that the clinic is clean and that standard infection control practices are in place and practiced by all employees.

  • Safety protocols, including staff knowledge of facility “code” responses, and facility emergency response protocols for various safety situations.

  • Emergency protocols, including drug kits and emergency oxygen supplies.

  • Drug storage and expiration dates, including both proper storage of material (i.e. temperature) as well as security of certain items such as anesthetic, pharmaceuticals, and anesthetic needles and syringes.

  • Facilities and biomedical maintenance.

  • Policy and Procedure manuals (with approval at a higher level of the organization).

  • Medical records documentation, including protocols for ensuring continuity of care in the event that patient dental charts are separate from patient medical charts, and compliance with local and IHS standards.

  • Informed consent–along with a clearly defined policy and procedure on informed consent within your Departmental manual, informed consent forms should be available for review. Forms for oral surgery, endodontics, nitrous oxide use, and conscious sedation should all be considered for use within a dental department. As physically marking surgical sites intraorally can be impractical due to many factors, a patient informed consent form should be considered that includes a visual representation of the mouth, enabling patients to mark the effected area (i.e. the tooth to be extracted) on the form, in an effort to ensure proper treatment is completed.

  • Official policy/guidelines to address type, frequency and indications for diagnostic radiographs taken.

  • Ensure that at least one quality assurance study is ongoing in the dental program, and that this quality assurance study follows the format of:

  • Identify/quantify a problem–use RPMS or other database to obtain data to support the problem.

  • Propose solutions/interventions that may improve the problem.

  • Implement the interventions and reevaluate in a specific time period.

  • After reevaluation, make recommendations for further improvement to the problem.

  • Implement revised interventions and continue steps the above steps (see the following section for more detailed information on the PDCA cycle of quality improvement).

Of course, for complete preparation for an AAAHC survey, thorough review of the AAAHC Accreditation Handbook for Ambulatory Health Care should be completed.

Chapter 7-E-

Quality Assessment 2007



and Improvement


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