The Most Common Accreditation Problems in Orthopedic, Spine and Pain-Driven ASCs

At the 10th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference in Chicago on June 14, 2012, Nancy Jo Vinson, RN, CASC, principal at NJM Consulting and surveyor at the Accreditation Association for Ambulatory Health Care, discussed the most common accreditation challenges in orthopedic, spine and pain management-driven ambulatory surgery centers.

First steps to preventing problems include obtaining an appropriate AAAHC handbook, conducting a self-assessment and identifying what needs to be put in place to address and understand the standards. Next steps require a teamwork approach and policies and procedures to ensure compliance to the AAAHC standards.

Frequently overlooked adjunct chapters include health education and health promotion, teaching and publication activities, research activities and overnight care and services. Specific standards that frequently prove to be problematic include:

•    Providing appropriate patient privacy, which starts at check-in
•    Compliance with CMS requirements
•    Risk management, safety and infection control and quality program
•    Credentialing and privileging
•    Peer review programs
•    Designated and qualified healthcare professional
•    Food services
•    Malignant hyperthermia protocols

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