OR Manager - September 2019 - 2

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Advanced Orthopaedic Certification Focuses on Patient
Outcomes, Builds on Accreditation Requirements
Orthopaedic procedures are on the rise, particularly in
the outpatient setting, where patients, providers, and
payers can enjoy lower costs and increased efficiency.
To stand out from other facilities in the industry and
demonstrate a commitment to patient safety and
quality of care, many ambulatory surgery centers
(ASCs) are obtaining official certification in orthopaedic
procedures from an accrediting organization.
Building off accreditation and focusing on specialty care,
the certification standards concentrate on transitions
of care from pre-assessment through
discharge and rehabilitation. It
is important for facilities seeking
advanced orthopaedic certification
to create a robust plan and follow
specific steps to ensure compliance
with the requirements and avoid
jeopardizing a successful outcome.
These elements should include
conducting a gap analysis, developing
a plan for improvement, and implementing changes.
Outlined below are seven key steps to help facilities plan
accordingly when preparing for a certification survey.
4. Develop a Plan for Improvement
The Plan for Improvement (PFI) can help your
organization reduce risk, teach staff and identify an
area for a quality improvement study. A PFI consists of
six elements:
¡ Deficiency Statement
¡ Corrective Action
¡ Responsible Party
¡ Correction Date
¡ Monitoring Activity
¡ Supporting Documentation
5. Implement Actions and
Advanced orthopaedic
certification focuses on
leadership effectiveness
and care integration
in the delivery of
orthopaedic services.
Submit Application
Be sure to revise documents, policies
and procedures to reflect best
practice and communicate changes
through memos or training sessions.
Then, submit your application with
supporting documents.
1. Identify Core Leaders
The first step is to identify the core leaders appointed
to direct the specialty service, which should include a
medical director and a clinical resource person.
2. Develop a Project Plan
Create a project plan or action plan that is continuously
reviewed and updated, and which may form the basis
for your quality improvement efforts as well.
3. Conduct a Gap Analysis
A gap analysis is used to assess an organization's
scope, readiness for certification and resources for
compliance.
6. Report Findings
Report the findings of deficient practice and any
changes that occur as a result of process improvement.
Collect all documented evidence that the change
occurred, and that it was properly communicated and
reported.
7. Conduct an Internal Audit
Cross verify that all documented activity is congruent
with staff knowledge and observed in their practice.
An internal audit focuses on verifying that your written
processes are being implemented and are effective.
These steps can also be utilized in the annual review
of your organization's compliance with the advanced
orthopaedic certification and will be required for the
completion of an annual attestation.
To contact the AAAHC Orthopaedic Certification Team, email orthopaedic@aaahc.org,
call 847-853-6060, or visit http://www.aaahc.org/certification.
35280
http://www.aaahc.org/certification
OR Manager - September 2019

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