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The Surgery Center Accreditation Checklist: Most Commonly Overlooked Survey Items

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The following is a list of the major items overlooked in ambulatory surgery center accreditation, as noted by the three major ASC accreditation agencies: Accreditation Association for Ambulatory Health Care, The Joint Commission and the American Association for Accreditation of Ambulatory Surgery Facilities.

Numbered items below are not specific standards but pertain more to general areas of topical trouble for ASC accreditation and reaccreditation.

The Joint Commission
1. Organization has appropriate credentialing and privileging process.

2. Organization reduces infection risk associated with sterilization of medical devices or supplies.

3. Organization safely stores medication, including having procedures for dealing with expired medication and storing look-alike or sound-alike medications with proper segregation.

4. Organization performs a risk analysis for infection transmission risks due to the community, facility and patient population.

5. Organization safely manages medication, including high-alert and hazardous medications and look-alike or sound-alike medications.

According to Michael Kulczycki, MBA, CAE executive director of The Joint Commission's Ambulatory Accreditation Program, credentialing and privileging is spending its third year on as number one on the list of problematic accreditation standards. "Compared to hospitals, where they have whole teams devoted to credentialing, in an ASC it's often handled by someone who already has three to four other principle duties. The process is detailed, requires precision and requires detailed tracking of dates, times and deadlines. If an organization doesn't have a person with those kinds of skills, that's often where they may fall short," he says.

He notes that as ASCs are developing compliance strategies, The Joint Commission has experts available for customers by email and phone, at 630-792-5900, option 6.

Accreditation Association for Ambulatory Health Care
1. Healthcare professionals are legally and professionally qualified for privileges granted, including (but not limited to) anesthesia, fluoroscopy, laser, overnight care and supervision of anesthesia.

2. Presence and absence of allergies is clearly recorded both prominently and consistently and is continually updated with each patient visit and when new allergies are identified.

3. Organization follows an appropriate schedule of emergency preparedness drills.

"Aside from the issues associated with the quality improvement standards, we've known credentialing and privileging is not easy, because it requires persistence, and it's repetitive. For emergency drills, organizations may not understand that documentation and improvement in emergency drills is important, and it's an issue. That was an issue we didn't necessarily expect," says Naomi Kuznets, PhD, senior director and general manager for the AAAHC Institute for Quality Improvement. "We urge centers to take advantage of educational programs and materials, to read the AENEID and to look at their performance compared to trends to identify potential trouble issues. And, as always, we're very approachable and willing to help!"

AAAHC recently published a detailed report on the accreditation or reaccreditation standards with the best and worst compliance, titled AENEID, which is available for no charge online.

American Association for Accreditation of Ambulatory Surgery Facilities
1. Narcotic inventory and control records are dated and include the use of narcotics on individual patients and are kept in a tamper-proof book. The narcotic inventory is verified by two OR team members at least once a week, days narcotics are administered and per state regulations.

2. Surgical logs are complete and include a numerical listing of patients, the names of the staff on the surgery, name of the person administering anesthesia and the type of anesthesia. A separate surgical log of major cases — processes done with more than local anesthesia — is maintained and is secure.

3. Continuing education is recorded.

4. Staff members have hazard safety training, including fire extinguisher training.

5. A biomedical technician performs an annual equipment inspection and submits a written report of the equipment's safety according to manufacturer specifications.

According to Thomas Terranova, MA, AAAASF's director of accreditation, while these standard areas are from 2012, the problematic standards have been relatively consistent since 2009 and are usually related to record keeping and log books.

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Joint Commission on Most-Asked Environment of Care Questions

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