ASC Accreditation Requirements: Mastering the Essentials

Ambulatory surgery center (ASC) accreditation is a process designed to help ASCs adhere to the complex rules and regulations they’re subject to at the federal and state levels. These requirements are in place for good reason: They help ASCs maintain patient health and safety. But it can feel intimidating to navigate this compliance landscape alone.

By working with a third-party accrediting agency, ASCs can receive much-needed support and a framework for meeting federal and state requirements. Adhering to ASC accreditation requirements can also help your surgery center achieve higher standards of care and demonstrate its commitment to patient safety. This can go a long way toward building trust with patients, payers, and providers.

All that said, where can you start? In this blog, we’ll explain the core accreditation requirements ASCs should strive to meet, provide best practices for maintaining compliance on an ongoing basis, highlight how technology can support accreditation readiness, and more to help you master the essentials of ASC accreditation.

What Are the Core Ambulatory Surgical Center Requirements?

Ambulatory surgical center requirements can vary widely, especially if your center provides multiple specialties and services. However, there are a few key areas every ASC should prioritize:

Staff Competency

Accreditation agencies will often vet staff to ensure that personnel are adequately trained, qualified, and competent. This includes verifying that staff have completed all requirements for employment and practice, evaluating the quality and completeness of education and training programs offered to staff, and confirming that there is enough qualified, licensed staff to meet the needs of the population the ASC serves.

Patient Care and Safety

ASCs must demonstrate a commitment to maintaining a culture of safety and delivering a high standard of care. To assess this, accreditation organizations may review your ASC’s mission, vision, and goals, review the codes of conduct that apply to both staff and patients, measure the level of care provided to patients, evaluate infection control protocols, and more.

Medication Management

Accreditation agencies will take a close look at your ASC’s medication management protocols, as these can pose serious risks to patient safety if improperly managed. They may check the labelling of medications, the use and placement of medication containers in the facility, the medication procurement process, the procedures followed when substituting medications during shortages, and more.

Documentation and Recordkeeping

The key to meeting compliance with ASC accreditation requirements is maintaining comprehensive records and organizing documentation clearly and comprehensively. Accreditation representatives will review your ASC’s documentation and recordkeeping practices to ensure accurate, timely, and compliant records. This involves accurately recording and storing all surgical cases, thoroughly documenting safety programs, ensuring they are easily accessible, and securely protecting all patient data.

Quality Improvement

Part of quality management is committing to continuous improvement. Accreditation agencies will thus ensure that your ASC has continuous monitoring tools in place, including regular reporting against key performance indicators and national performance benchmarks. They will also check corrective action programs and assess their effectiveness. Some agencies will even provide you with goals and frameworks to help your ASC go beyond the minimum compliance requirements.

Emergency Preparedness

ASCs must effectively respond to various emergency and disaster situations. Accreditation often involves a resilience review, where an organization assesses your ASC's emergency preparedness plan. This review evaluates your ability to protect patients, staff, and infrastructure during an emergency. It typically examines everything from emergency drills and response plans to life safety compliance and continuity of operations.

Data Privacy and Security

Due to the sensitive nature of patient data, ASCs must adhere to several data privacy protocols and security standards, such as HIPAA. Accreditation agencies maintain strict requirements in this area and will assess your organization’s patient information protection. This includes evaluating the technology your ASC uses to protect data (e.g., access controls, encryption), the procedures in place to ensure patient data privacy (privacy policies), the breach response plans and training programs staff must be trained on, and more.

What Steps Should I Follow for Ambulatory Surgery Center Accreditation?

Now that you know some of the core areas to focus on, how can you ensure they meet the necessary standards? Here are a few best practices and steps to follow for ambulatory surgery center accreditation:

• Improve your documentation. Getting your documentation in order is only half of the battle. You also need to invest time and effort into standardizing documentation and protocols. Develop templates for common documents, implement version control policies, and create easy-to-follow audit trails.
• Conduct regular internal audits. You can implement all the rules you want, but it won’t matter if no one follows them. To help prepare for ASC accreditation, conduct your own audits on a regular basis (quarterly for high-risk areas, like clinical documentation, annually for everything else) to assess adherence and performance and identify areas of improvement.
• Prep for surveys and run mock inspections. Review the ambulatory care standards and any additional criteria your accrediting organization may evaluate, and put together a mock survey. Assign someone to act as a surveyor, and see what they find. You might be surprised at what a practice run may surface.
• Train (and retrain) staff. Since ASC rules and requirements are always evolving, education and training must be ongoing. Provide regular training to your staff to make sure everyone is up to date with new standards, such as coding updates. Retrain your staff to reinforce concepts so that best practices become second nature.
• Integrate compliance into your culture. Accreditation is designed to help healthcare facilities minimize risk, protect patients, and deliver high-quality care. Bake these principles into your ASC’s mission and goals, and your entire staff will realize the importance of compliance. When you prioritize compliance, it will become part of your culture.

What Technology Can Help Fulfill ASC Accreditation Requirements?

Keeping track of all these requirements and implementing a strategy to meet them can be challenging without the right tools. Thankfully, ASC-specific technology can provide much-needed support and streamline every aspect of compliance.

Here are a few essential tools that can help you fulfill ASC requirements:

• EHR systems and other platforms with built-in compliance checklists that make it easy to keep track of, adhere to, and customize requirements.
• Learning management systems that help simplify staff training and retraining, allow you to track and manage completions, and build your own courses.
• Automated notifications that provide real-time status updates and expiration alerts for everything from credentialing to auditing reminders and beyond.
• Dashboards for quality monitoring and reporting that provide actionable insights into deadlines, compliance gaps, and performance at a glance.
• Policy and document management tools that securely store ASC policies, procedures, documents, and contracts all in one easy-to-access place.
• Digital logbooks that provide templates for crash cart checks, sterilization, temperature, and more with automatic time and user stamps.

SIS Comply combines many of these features into a comprehensive, ASC-specific platform, allowing you to easily manage ambulatory surgery center accreditation and compliance in one place.

Where Can I Find the Latest Information on ASC Accreditation?

While we’ve provided a brief overview of the essential ASC accreditation requirements here, the rules and standards are always evolving. How can you keep up?

First, the four major accrediting bodies for ASCs (AAAHC, Joint Commission, ACHC, and QUAD A) all have websites that will be your best bet for staying up to date. Make it a habit to check their “news” and “updates” pages regularly to find the latest information as it rolls out. All provide free resources, like blogs, podcasts, and newsletters, that deliver insights and updates frequently, as well as social media accounts you can follow.

Second, always keep an eye on the Centers for Medicare and Medicaid Services (CMS) website. CMS will upload new documents, provide related links, and update ambulatory surgical center requirements on their website. You can also sign up for email updates to get the latest information sent directly to your inbox from CMS. In addition, you should follow the CMS Conditions for Coverage page. They typically announce updates well in advance, but at the very least, you should check in annually to keep current.

Finally, it may be a wise idea to seek out independent sources of information. For example, industry associations, like the Ambulatory Surgery Center Association (ASCA) and the ASC Quality Collaboration, and ASC-specific publications, such as ASC Focus or ASCA News Digest, may provide a glimpse into the future trends of care or offer some industry-standard best practices you can adopt and implement in your own practice. This is an effective way to stay up to date with others in the field, ensuring you’re always on the lookout for new insights and continually elevating patient care and safety and the delivery of services.

The Importance of Continuous Accreditation

Learning these essentials and following best practices can help form a solid foundation for ASC accreditation. However, you can’t stop there — ASC accreditation must be a continuous process since the requirements evolve over time. Keeping pace with changing rules and regulations can help ensure your ASC remains organized, efficient, and compliant.

Practicing continuous accreditation comes down to being strategic in meeting requirements. As such, aim to develop an accreditation strategy that balances people, processes, and technology.

Stay survey-ready and stress-free with SIS Comply. Simplify accreditation, streamline training, and keep every compliance requirement in one secure platform. Contact us to learn more.

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