Fifteen years ago, just about any procedure connected to the word "surgery" required at least one, and usually several, nights in a hospital. But these days, a person undergoing any of a number of procedures is likely to leave the recovery room in plenty of time to spend the night at home.
Since 1985, the likelihood of certain procedures being done on an outpatient basis has more than doubled, according to the National Center for Health Statistics; about 65% of surgeries are performed on an outpatient basis. The drive behind this dramatic shift is twofold: Recovery time has been reduced by advances in anesthesiology and surgical techniques, and soaring medical costs have prompted a push from insurers toward outpatient care.
This trend, coupled with the few highly publicized deaths that occurred after outpatient surgery in recent years, has focused a lot of attention on the quality of outpatient surgical care. Unlike hospitals, which have long been subject to critical oversight and undergo regular accreditation reviews, the process of formal accreditation is relatively new to outpatient surgical centers.
Though many states require credentialing for selected outpatient procedures, only three states--California, Florida and New Jersey--mandate accreditation for all outpatient surgeries. However, that number is expected to rise: Medical boards in several states are in the process of reviewing existing regulations with an eye on the need for mandated accreditation.
"I'd say now we're in a quasi-regulation stage," says John Burke, executive director and CEO of the Skokie, Ill.-based Accreditation Association for Ambulatory Health Care. The AAAHC is the leading accrediting body for the nation's approximately 18,000 outpatient surgical centers.
"(The push toward mandatory accreditation) is unfortunate because we have always prided ourselves on the voluntary nature of our process," he says. "Still, mandatory accreditation accounts for only 25 percent of our work."
The value of any recognized stamp of accreditation, whether it's voluntary or mandated, is the evidence it presents not only to patients and peers but also to private and government payers that procedures are being performed according to national quality standards.
In practical terms, that translates to increased protection in the event a provider is sued for malpractice and fewer hassles contracting with payers. More personally, accreditation gives physicians the satisfaction of knowing they are providing quality care.
Margaret Spear, M.D., director of University Health Services at Pennsylvania State University, voluntarily put the school's health services program through the AAAHC accreditation process. She has since signed on as a volunteer surveyor with the association.
"There is a surge in accreditation (for outpatient facilities) now, and I think it's customer driven to some extent," Spear says. "Private and organization customers are looking for some guarantee. There are a million alternatives, and they want some help figuring out which are best."
Despite the growing mandates, Spear believes that going through the certification process voluntarily is still the best route. "It was a decision we made as an organization," she says. "And it was probably one of the best things we've done to promote staff morale and team building.
"That kind of effort cannot be accomplished without the majority of people committing to it and helping to make it happen. It's a great experience when you're successful. And there's no question that because of the process, we feel we're providing better care."
The first series of reviews are the most difficult, Spear says. Follow-up is easier because a certain level of energy and vigilance has been established. For example, continuing education for physicians is inherent to maintaining standards, she says.
One unexpected benefit of accreditation is the relationships the school's health services now has with managed-care organizations. "One came in for a review and was amazed at the level of sophistication and the fact that our standards far exceeded its own," Spear says. "That made us feel great."
Though standards by accreditors are continually revised, the typical AAAHC accreditation, for example, would include a review of quality of care, quality of management, records keeping and other administrative procedures, environmental safety and professional development.
Entities that undergo the accreditation process are given a description of the standards well in advance of the reviews to allow time for improvement where it may be needed. Still, it's not unusual for surveyors to spot areas that require further work and then make additional visits.
The cost of an AAAHC review varies depending on the size and range of services a group or facility offers. As a rough guideline, the association lists $3,000 to $4,000 as the fee for reviewing a small group, which is defined as one to three physicians who perform one or two procedures. The fee for a multispecialty group--four to 20 physicians performing two or three procedures--is listed as $6,000 to $10,000. Multispecialty groups with more than 20 physicians performing a variety of procedures can expect to pay approximately $10,000 to $12,000.
"The reason the AAAHC came into existence," Burke says, "was that physicians wanted to set and meet high national standards for quality care. It is one of the few pure peer-review systems left."
The range of facilities and organizations that receive accreditation from the AAAHC includes single-specialty and multispecialty group practices, office-based surgery centers, college health services, HMO providers and various other nonhospital providers.
The not-for-profit organization receives guidance and financial support from the 12 major healthcare associations that make up its membership. Among them: the American Association of Oral and Maxillofacial Surgeons, the Association of Freestanding Radiation Oncology Centers, the Medical Group Management Association and the Outpatient Ophthalmic Surgery Society.
The AAAHC recently signed an agreement with the Joint Commission on Accreditation of Healthcare Organizations, the next-largest accreditor of outpatient surgery centers, that would eliminate the duplication of evaluation processes. Under the agreement, an AAAHC-accredited ambulatory surgery center is not required to undergo a separate accreditation survey if it joins a JCAHO-accredited healthcare network.
The AAAHC is one of only two organizations--the JCAHO is the other--granted authority by HCFA to certify ambulatory surgery centers for Medicare.
Because many HMOs voluntarily called on the AAAHC to conduct surveys in the 1980s, the organization's accreditation now is viewed by many managed-care organizations as the substitute of choice for the various credentialing processes that previously were done in-house.
AAAHC has status as an approved accreditation entity for HMO outpatient surgical facilities in Florida, Kansas, Oklahoma and Pennsylvania. Along with the California Medical Association and the Medical Board of California, it is an approved accrediting body not only for HMO facilities but also for all California providers of outpatient surgery.
Mary Sellers, a spokeswoman for Louisville, Ky.-based Humana, says the organization requires that all its outpatient surgery facilities, at a minimum, have Medicare certification and a state license. If they don't also have accreditation, Humana begins the process of credentialing with a site visit.
"While accreditation for these services is still maturing," Sellers says, "the (AAAHC) is becoming the standard bearer for accrediting them. As is true of all quality measures, the AAAHC accreditation gives Humana yet another measure for ensuring that our members have access to high quality healthcare services."
Sam Romeo, M.D., a Los Angeles family practitioner and director of the 2,800-member University Affiliates IPA, sits on the executive committee of the AAAHC and is head of its survey and education committee. He believes that physicians need to be more accountable for what they do.
"To be held to high standards by an outside agency is a professional responsibility," he says, "which is why (University Affiliates) was accredited long before the state's legislative mandate. Setting standards is a very dynamic process, and no one can keep up alone."
Though Romeo, like Spear, thinks the optimal path to accreditation is voluntary, he suggests the current legislative push for mandatory standards speaks to the ways the process serves to protect the public.
"Review shouldn't be a 'gotcha,'" Romeo says. "It should be a process of continuing education and raising the bar on quality of care. It shouldn't be viewed as hostile."
W.A. Weronka is a Los Angeles-based business writer.