Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
04.03.01 Risk Management Program Frequency of the citation: 27%
Overview of the requirement: The ASC identifies and assesses potential risks across the organization. It has an established process to identify and review unanticipated events and uses data, analysis, and action to mitigate negative outcomes. Comment on deficiencies: Compliance is assessed through review of the written Risk Management Program. Most deficiencies cited one or more missing required element.
Examples of ACHC Surveyor findings:
■ The program lacked a review of data security risks. ■ The program did not consider medication errors, patient deaths, or data security among the risks assessed. ■ The ASC lacks a risk management plan.
Compliance tips for:
Quality improvement is the primary goal of accreditation. The intent of this standard is to ensure that quality metrics are established and monitored and that corrective action is implemented when performance falls below established thresholds. ■ Think of the annual QAPI plan as a collection of measures specific to each area/department/team in the ASC. ٝ .Audit data you are currently collecting and assign it to services to ensure all areas of the ASC are included. ٝ Audit to ensure a goal is established for each measure. Note: Trending your data over time establishes internal benchmarks and researching national industry norms can provide external benchmarks. Use these to create your goals. ٝ Audit the annual plan to ensure each required element of the standard is addressed. ■ Analyze current performance against goals. Where performance falls short, you have opportunity for improvement. The annual plan should prioritize action in those areas where risk, volume, incidence, prevalence, or severity are high. Select quality improvement activities with potential for positive impact on patient safety or quality of care. ■ Share improvement projects in progress and when completed with all staff.
Compliance tips for:
Nerd Newbies (understand the requirement)
The standard identifies seven categories of risk that must be assessed at minimum: ■ Unanticipated events. ■ Deaths. ■ Complaints. ■ Grievances. ■ Patient falls. ■ Medication errors. ■ Medical malpractice claims. ■ Data security risks. There must be a process to report unanticipated events and these are reviewed and acted on. ■ Audit the program for inclusion of all required elements. ■ Audit the policy/procedure for reporting unanticipated events. ■ Conduct staff training on the reporting process. ■ Incorporate the findings of individual event review into the risk assessment to ensure mitigation plans are enacted and effective.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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