ASC Accreditation: Understanding Your Surgery Center’s Options

Ambulatory surgery centers (ASCs) are often required to or voluntarily choose to undergo a process called accreditation. ASC accreditation involves an external inspection that evaluates compliance with healthcare standards and assesses a variety of quality metrics. Going through accreditation may be required to receive a state license or certification for programs like Medicare. These inspections are usually performed by a representative from a third-party accrediting organization or a state or federal representative.

Going through the accreditation process is critically important, even when not required. It can help ASCs identify areas of improvement, ensure compliance with the highest standards, enhance patient safety, and streamline performance. Obtaining licensure and accreditation can also help build trust with patients and partners, as it demonstrates your ASC’s commitment to quality and safety.

However, accreditation can be difficult to navigate, and you may have some questions, like does your ASC need accreditation, or which ASC accrediting organization should you trust? We’re here to help you understand when you might need accreditation and why, who can perform the process, and factors to consider when selecting which organization might fit your ASC best.

Does My ASC Need to Be Accredited, and Why?

ASC accreditation is mostly voluntary; however, some payers and states may require it in addition to or in place of federal requirements.

It’s important to clarify the difference between accreditation and certification. The Centers for Medicare and Medicaid Services (CMS) require ASCs to meet specific Conditions for Coverage to gain Medicare certification. In other words, if your ASC wants to receive payments from Medicare and Medicaid, you must earn CMS certification. The same applies to other payers who may require ASC accreditation for reimbursement.

Accreditation is not the same as certification; however, it can provide a pathway to earning certification. Accreditation is also focused on the entire organization, whereas some certifications may only focus on specific programs within an organization.

CMS’s Conditions for Coverage can be difficult to navigate. The conditions span everything from complying with state licensure laws to meeting specific safety and quality standards, such as infection control and disaster preparedness planning. CMS recognizes this fact, so to make the process easier, it has granted a “deemed authority” designation to certain accreditation organizations. These authorities can help ASCs meet state and federal regulatory requirements and standards, earn certifications and licenses, and achieve higher standards of care.

For these reasons and more, most ASCs choose to go through accreditation and work with accreditation bodies, even if they choose to do so voluntarily. Accreditation can also demonstrate your organization’s commitment to patient safety and quality, which can send a powerful message to patients, payers, and providers.

What Are the Major Accrediting Bodies for ASCs?

There are four major accrediting bodies for ASCs:

• Accreditation Association for Ambulatory Health Care (AAAHC): AAAHC, also known as the Accreditation Association, has served ASCs for more than 45 years and is recognized as a deemed authority by CMS. AAAHC provides several programs to help ASCs meet accreditation, including Medicare deemed status accreditation, as well as programs to help ASCs earn certifications for specialties, like Advanced Orthopaedic Certification. AAAHC accreditation typically involves a peer-based review process that is tailored to your ASC based on an accreditation application you can submit for a fee. The programs generally cover the entire organization, and surveys are designed to assess criteria such as compliance with applicable federal, state, and local laws and regulations, and the facilities, equipment, and records involved with patient care and how they’re handled.

• Joint Commission: Joint Commission has served ASCs for 45 years and is recognized as a deemed authority by CMS. Joint Commission standards are specifically designed for ASCs, providing an industry-vetted framework to help ASCs minimize risk and improve care and services. The program requirements typically focus on staff competencies, patient assessment, medication management, and infection control, among other criteria. In addition to accreditation, the Joint Commission offers performance measurement for internal quality improvement, which can help in developing strategies to address more complex operational issues and identify vulnerabilities in patient care.

• Accreditation Commission for Health Care (ACHC): ACHC, formerly known in part as the Healthcare Facilities Accreditation Program, has been recognized as a deemed authority by CMS since 2003. ACHC accreditation covers initial, transitioning, and renewal accreditation. ACHC also offers a program to help earn Joint Replacement certification, including Advanced Joint Replacement and Advanced Joint Replacement with Distinction certification. ACHC standards focus on risk management, quality, and education. The organization also offers an accelerated accreditation program for new ASCs to help explain the accrediting process, expedite survey reports, and get your ASC up and running to ease the financial burden of just starting out.

• QUAD A: QUAD A, formerly known as American Association for Accreditation of Ambulatory Surgery Facilities, has been recognized as a deemed authority by CMS since 1998. QUAD A accreditation requires surgeons to be board-certified, peer review and data reporting, the use of qualified anesthesia professionals, and that ASCs must be held to hospital-level standards of safety and quality, among other criteria. QUAD A accreditation can usually be completed in 90 to 150 days and is valid for 3 years, provided that ASCs complete annual self-surveys. QUAD A is committed to patient-centric care and ensuring that all ASCs rise to their high standards of quality care.

While each accrediting body may approach the process differently, they all share the same mission: to help ASCs demonstrate their compliance with regulatory requirements and standards and their commitment to patient safety and quality.

How Do I Know Which ASC Accrediting Body Is Right for My Surgery Center?

Deciding which ASC accrediting body is right for your center comes down to a few specific factors. Consider the following:

• Size: ASC accreditation fees vary based on the size and scope of the facility. Some accrediting agencies specialize in serving larger ASCs, while others, like the accelerated ACHC accreditation program, gear their services toward newer, smaller ASCs. Typically, you can find pricing on each accrediting agency’s website based on size, but some may require a consultation for a quote.

• Specialty mix: If your ASC seeks accreditation or certification for specific specialties, you’ll want to carefully consider which accrediting body you choose to partner with. Some accrediting bodies, like AAAHC, offer assessments for specialties, while others may not have the specific expertise you’re seeking.

• Cost: Accreditation costs can vary depending on a variety of factors, including the type, size, and range of services your ASC offers. For example, the accrediting agency may need to send additional surveyors if your campus is larger than normal, or they may need to extend your review timeline if you offer a long list of services that each need to be evaluated. Accrediting bodies also approach pricing differently; some may refund application fees, while others may not, for example. It’s important to note these cost differences and weigh the pros and cons before making a decision.

• Reimbursement: Medicare is not the only payer you may be interested in. Each accrediting body works with different payers. If you’re interested in casting as wide a net as possible and gaining approval from a variety of payers, you may want to vet the accrediting bodies based on how comprehensive their assessments are. The more standards and regulations you can adhere to, and the more support you can gain from the accrediting body, the more payers you can potentially gain approval from and work with. This can directly affect the amount of reimbursement you’re able to receive.

In addition to the above factors, consider the values and goals of each accrediting body. Do they align with your ASC’s values and goals? Do they prioritize patient safety? Do they have high standards for care quality? Do they understand the unique goals of ASCs in the wider healthcare landscape? Answering these questions can help narrow down the options available.

Taking a Proactive Approach to ASC Accreditation

While ASC accreditation may not be required in your area, it’s still important. It can help ensure your ASC is adhering to rules and regulations and achieving the highest standards of patient care and safety. This can go a long way toward streamlining compliance, keeping money flowing in and out of the organization, and building trust with patients and partners.

That said, it’s also vital to weigh your options. Consider the factors we’ve outlined here when deciding which accrediting organization to work with, and make an effort to proactively prepare for surveys to make sure you pass with flying colors. Many ASCs benefit from internal mock surveys or partnering with a third-party consultant for a comprehensive practice run. These exercises help identify compliance gaps early, strengthen staff readiness, and ensure your facility aligns with surveyor evaluation standards. This will cause fewer headaches and give you peace of mind that you’re doing everything in your power to deliver high-quality care at scale.

Reach out today to learn how Surgical Information Systems can help your ASC secure accreditation.

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