Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
AMBULATORY SURGERY CENTER
This Quality Review edition of Surveyor identifies and analyzes the most challenging standards for ambulatory surgery centers based on data from initial and renewal surveys conducted between June 1, 2024, and May 31, 2025.
Trending the Data Fourteen standards were “not compliant” on more than 25% of the surveys conducted. The three that appeared most often are carryovers from last year. Compliance with standard 03.01.02 Credentialing Files can be simplified by using the required elements as steps. 1. Verify education, licensure, certification, etc. 2. Verify procedural logs, peer reviews, and/or other submissions for evidence of current competence. 3. Confirm reappraisal prior to renewal of privileges. 4. Governing body reviews recommendations from professional staff regarding the applicant. 5. Include a letter granting, denying, or adjusting the scope and duration of privileges. There is no point in reviewing procedural logs, or peer recommendations (step 2), if licensure or certification (step 1) are in doubt. The final step is the letter regarding appointment and privileges that comes from the governing body as confirmation that it has reviewed all relevant material and assumes responsibility for the care this individual will deliver to the ASC’s patients. Deficiency of the infection prevention and control standard 05.00.06 Sanitary Environment will always be a challenge because of the constant change, and wear and tear on the physical environment of the ASC. The best way to improve your level of compliance is to engage all staff
in observation-based environmental rounding. Look at the state of cleanliness and create work orders when dirt, dust, and debris are noted. It’s also important to note that the goal of efficient OR turnover cannot be allowed to undermine infection prevention goals. Establish and follow a process for post-case cleaning of ORs that defines the cleaning agents to be used, dwell-time, waste management, etc. Finally, standard 08.00.03 Form and Content of the Medical Record continues to present challenges for full compliance. The medical record is the complete story of each patient’s health and procedural journey in your ASC. It serves to support continuity of care among providers for each case in the event of an emergency transfer to a higher level of care, and for routine follow-up care. Surveyors noted patient records missing risk assessments, missing anesthesia documentation, and missing dates, times, and authentication. This is a matter of training and building a culture of quality and attention to detail. How can we help? The purpose of this report is to highlight topics of common concern for ASCs. Additional resources are available on the refreshed ACHC website (achc.org/articles), including posts from ACHC experts that support compliance with the standards in this report and others. Also, please visit our education division, ACHCU (achcu.com/ ambulatory-surgery-center-webinars/) for a library of free resources to help your ASC excel.
AMBULATORY SURGERY CENTER ACCREDITATION
FREQUENT DEFICIENCIES FROM ASC SURVEYS
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 01.02.01 02.01.05 02.01.08 03.01.02 04.01.01 04.03.01 05.00.0205.00.0606.00.0308.00.0309.00.03 09.02.02 09.03.01 15.01.02
Physical Environment
Medical Staff
Quality
Infection Control
Patient Rights
Governing Body
Medical Records
Patient Assessment
Administration & HR
Rommie Johnson, MPH Program Director
achc.org | (855) 937-2242 | 5
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