The process of becoming accredited can be arduous, but once achieved it provides benefits to everyone associated with that health care facility. The various accreditation societies evaluate facilities to ensure that they are meeting quality-of-care measures, and a focus on process improvement often results in more effective organizations that achieve improved patient outcomes.
“It’s like getting the Good Housekeeping Seal,” says Keith Granger, CEO of Trinity Medical Center. “Accreditation is an independent verification that we meet certain standards, and it is something that says to our employees, physicians and external audiences that we provide excellent health care.”
Granger says that going through such a critique challenges an organization to be its best. “It is about reaching a standard and when you achieve it you want to continue to improve,” he says. “It is about measurements and continuing to improve year after year.”
Trinity recently received a three-year accreditation with Percutaneous Coronary Intervention from the Society of Cardiovascular Patient Care (SCPC). More than five million Americans visit hospitals each year with chest pain. SCPC’s goal is to reduce the mortality rate of these patients by teaching the public to recognize early symptoms of a possible heart attack, reduce the time it takes to receive treatment, and increase the accuracy and effectiveness of treatment.
SCPC’s accreditation process ensures that centers meet or exceed quality-of-care measures in acute cardiac medicine. The accredited Chest Pain Center at Trinity Medical Center has demonstrated its expertise and commitment to quality patient care by meeting or exceeding a wide set of stringent criteria and undergoing an onsite review by a team of SCPC’s accreditation review specialists.
Sherry Cole, RN, spearheaded Trinity’s efforts. “There are eight key elements we looked at relative to overall care. We are required to meet certain items within each key element,” she says. “We determined which items would help us improve our care the most and focused on those.”
Of optimal importance was their demonstration of how they provide community education efforts. “We outlined how we provide community education on the risk factors of a heart attack. We listed dates, times, audiences, and what information we provide to these audiences,” Cole says.
The integration of Trinity’s Emergency Department with local Emergency Medical Services (EMS) was another element examined in the accreditation process. “We have a lot of activity in that area,” Cole says. “We recently held a leadership workshop to coordinate our emergency efforts with EMS. We provide support to them and give them feedback when they do a good job with a cardiac patient.”
EMS members were involved in the site visit when the accreditation team came to Trinity, and they provided feedback on the medical center’s processes and how they could work with Trinity. “We recognize that EMS does a great job getting patients to us quickly and in the best possible condition,” Granger says. “But we realized that EMS doesn’t always know the outcomes of these cases. We give them feedback so they know they did a good job. We are pleased with the initiative, and it is important to EMS.”
Granger says using accreditation processes encourages all associates to do a better job of keeping education and technical skills up to speed. “The challenge of meeting accreditation is that it improves care processes and individual staff performance. Even if you don’t succeed in receiving accreditation, you are striving to make the patient care process better,” he says “This is not an easy process, and I am proud of the whole staff and the work they did to receive this accreditation.”
Colleen Ingram, administrator at Total Skin & Beauty Dermatology Center, agrees that going through the accreditation process benefits all who are involved. Their center recently received a three-year accreditation from the American Association of Ambulatory Health Care (AAAHC).
“The accreditation makes us examine ourselves as a practice. We stripped everything down to the bone and put it back together again according to their standards,” she says. “We have looked at every aspect of our practice and are doing things according to the highest standards out there.”
Erica Walker, a recent Health Services Administration graduate from UAB, joined their organization to work full time on the accreditation process. The procedures are complex and were made even more so because of the size of the practice which has more than 70 employees. “Accreditation covers everything, the medical staff and administration,” Walker says. “We set up a peer review program and examined quality management, among many other tasks. We have to look at everything.”
Ingram points out that the accreditation process is heavy on infrastructure and the governance of the organization. “They looked at how we set up lines of communication within the organization and our processes. Most practices have that in place in the organization, but taking it apart and looking at things from the AAAHC criteria was a complex process,” she says. “Quality improvements and risk management were things we looked at. How do we look at things to improve? Basically, we took everything apart at the seams and put it back together and had people check our stitches.”
The quality improvement program was the most difficult part of the process in Ingram’s opinion. “In the past, when a physician told us he didn’t like the way something is done, we would just change the process to do whatever he suggested. Now we run suggestions through a structured process and look at them in an analytical and non-biased way. Taking the process and laying it out in a structure is hard but very practical,” she says. “The toughest part was setting up the system. Now that we’ve done it, I see the value of setting up the initial process well and not just focusing on the process itself.”
Ingram says the accreditation process was an eye-opening experience. “Our entire staff, as a team, was invested in this. Erica spent time with every employee,” she says. “It was a big team-building exercise. We all can give ourselves a big pat on the back for receiving the accreditation.”