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In health care, there are usually a lot of people watching — patients, colleagues, and most notably, accrediting agencies. Although hospitals have been surveyed for years, until recently, accreditation requirements for ambulatory care centers nationwide have been hit or miss. Even today, only a few states require accreditation.

Recognizing that accrediting bodies often function as change agents to improve the quality of care, ambulatory care centers throughout the country are electing accreditation. The services offered in these centers have changed; advances in technology and techniques have moved many kinds of procedures and care out of the hospital and into facilities that have no accommodation for an overnight stay.

These free-standing ambulatory care facilities are growing in number and are staffed by healthcare professionals who are dedicated and experienced in their field. A facility may offer a variety of surgical services, diagnostics, and treatments. The nurses and other professionals demonstrate their competence by earning accreditation for their organization from the Joint Commission as well as from a specialized agency like the Accreditation Association for Ambulatory Health Care (AAAHC).

Special services, special measures

Founded in 1979, AAAHC has been surveying ambulatory facilities and setting standards for quality ever since. The Accreditation Association offers accreditation for a variety of healthcare organizations, including free-standing ambulatory healthcare clinics, women's health centers, university and college health centers, birthing centers, pain management centers, and ambulatory surgical and anesthesia centers.

What do these care centers have in common? They all have a commitment to excellence and are willing to put themselves on the line to demonstrate it.

"Our long experience in ambulatory care gives us a unique perspective when we are looking at the care in this setting," says Michon Villanueva, assistant director for Accreditation Services, AAAHC, Skokie, Ill. She points out that the organization has a peer-based and educational approach, which fosters growth in AAAHC-accredited organizations.

The surveyors are volunteers who are practicing professionals and are trained and evaluated by the association. Villanueva reports that the collegial approach to the accreditation process makes it a valuable experience for the surveyor as well as for the facility being surveyed.

Nurses have an essential role in the process, says Marsha Wallandar, RN, BA, assistant director for Accreditation Services, AAAHC. Ambulatory care is not a "one size fits all" accreditation process, and there are criteria that are specific to surgical centers and all other types of centers.

"Nurses in ambulatory care are involved at key points in the development of policies and procedures, to be sure the facility meets standards of care," she says. "Peer review, quality improvement, and risk management are all areas in which nurses have expertise that helps a facility to meet the standards of care."

Commitment to quality

Julianna Brickner, RN, BSN, CGRN, director of Nursing, Endoscopy Center of Bergen County, Paramus, New Jersey, always reminds her staff that patients are the first priority. This facility applied for accreditation as a way to demonstrate that commitment to the highest quality of care. The center offers endoscopy, colonoscopy, biopsies, and endoscopic ultrasound (EUS) procedures. They wanted an accreditation that recognizes the unique aspects of the ambulatory care setting.

"We offer patients the best care possible — we treat each one as if he or she were a family member," she says. "Little things like warming the blankets that cover the patient in the preop area make the patients' experiences more pleasant and keep their temperatures at appropriate levels."

As part of maintaining accreditation, Brickner and staff are required to perform at least two performance improvement (PI) studies each year. They found that patients' temperatures tend to drop and are low postoperatively. The warmed blankets were a response to this finding and solved the problem. Patients reported that they enjoyed the warm feeling while waiting for surgery, and patient satisfaction surveys confirmed this.

"We pay attention to all variances in the records and surveys; that is the best way to maintain the highest quality of care," says Brickner. The overall culture reinforces that everyone who works at the center has an important role in the care of every patient. Brickner is passionate about caring for all patients in the most compassionate way. She reminds staff regularly that keeping the caring in the care makes all the difference. Brickner knows that most of her clients arrive frightened and anxious and need reassurance.

Mary Vongas, RN, MPA, Nursing director, Middlesex Surgery Center, Edison, N.J., is of the same mind. The center offers a wide variety of services and is staffed by 12 full-time RNs and 40 physicians. The free-standing surgical center offers endoscopy and colonoscopy procedures and has surgeons who specialize in orthopedics, plastic surgery, ENT, and pain management, including laser-assisted microdiscectomy.

Keeping everyone involved

"Because of the range of services we offer and the number of people involved in caring for our patients, communication is an important part of maintaining quality," Vongas says. "I post findings of our PI activities everywhere so that staff is kept informed. All staff members are interested in the results, because everyone wants to be successful. Everyone pitches in."

One way to promote staff "buy-in" about quality improvement activities is to get them involved in developing processes and programs. Vongas notes that they have some of the same committees as a much larger hospital, but that they have fewer problems accomplishing changes.

"We can pull together a committee of four, look at a problem, and make changes more quickly than a facility with many layers of administration," she says. The outcomes measurements confirm that patients are satisfied with the care that Vongas and her staff offer. In patient satisfaction surveys, 98% of patients rated their care overall as good or excellent.

When the right thing happens

At the Paramus Surgical Center, the effort to maintain quality services is always a team effort. It is a free-standing surgical center, which is accredited by the Joint Commission and AAAHC. They sought accreditation, says Judy Boehm, RN, CASC, director of Nursing, to demonstrate their commitment to the highest quality of patient care. She points out that the accreditation process doesn't stop with the survey.

"Both the Joint Commission and AAAHC require self-assessment and corrective actions. Continuous compliance with the standards directly contributes to the maintenance of safe, quality care and improved organizational performance," she says.

Efforts toward quality assurance translate to ongoing staff education and careful staff selection. At Paramus Surgical, new staff members are asked to start as per diem employees so that they can learn about the organization and have their skill levels assessed. The entire staff is involved in chart audits and patient safety committee activities, and the center belongs to the Foundation for Ambulatory Surgery in America (FASA). Boehm notes that this membership allows them to benchmark their activities against those of other ambulatory care centers.

Staff teaches, patients learn

Patient education is an important part of the overall quality effort. Preoperatively, an RN calls the patient to begin the education process. The nurses explain the upcoming procedure, perform a telephone assessment, and discuss what the patient might expect postoperatively. The day before the procedure, the appointment is confirmed by telephone and last-minute instructions are reviewed. Making patients partners in their care is another way to improve quality.

"If an organization does the right things and does them well, patients will have good outcomes," says Boehm. That concept is confirmed in the J.D. Power and Associates Distinction for Outpatient Service Excellence, which was awarded to the center for 2006 and 2007. The center is the first free-standing ambulatory surgical center in the nation to receive this honor.

If the true measure of a person is what he or she does when nobody is watching, all of these nurses are more than able to show that they can be trusted to do the right thing at all times, and they are willing to put themselves to the test to prove it. These ambulatory care centers are providing care that used to be limited to large hospitals with enormous resources. Using creativity and skill, they are matching the outcomes and patient satisfaction of much larger institutions.

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Marylisa Kinsley, RN, BSN, is a frequent contributor to Nursing Spectrum. To comment on this story, e-mail editorNJ@nursingspectrum.com.

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