Alabama Makes Accreditation Mandatory for Office-Based Surgery
By: Rommie Johnson, MPH, PMP, Program Director
Rommie Johnson manages the strategic and programmatic direction for Office-Based Surgery (OBS) Centers and Ambulatory Surgery Centers (ASC) seeking accreditation and certification through ACHC. His extensive experience includes accreditation of a wide range of ambulatory care organizations, as well as business development with a focus on complex surgical practices and surgery management firms. Rommie is a firm believer in sharing knowledge and is dedicated to building a team of highly collaborative surveyor-educators.
Posted: April 30, 2026
Here’s the good news: The single most important thing you can do to prepare for accreditation isn’t buried in a binder. It’s a shift in mindset. The practices that meet accreditation standards—and more importantly, deliver the safest patient care—also build a genuine culture of safety.
This is the foundation.
What “culture of safety” actually means for you
In a hospital or large ASC, safety culture is supported by layers of infrastructure built by risk managers, dedicated quality staff, and committees. In an office-based surgery setting, you likely don’t have any of that. It’s you, a small clinical team, and the patients who trust you.
That may actually create an advantage. A smaller team can build safety habits faster and more authentically than a hospital ever could. But it requires intentionality.
A culture of safety in an OBS practice means three things:
1. Every team member feels empowered to speak up. The surgical tech who notices the suction isn’t working properly before a procedure should feel completely comfortable raising that issue, even mid-case, and even if it causes a delay. If your team hesitates to flag problems because they’re worried about the physician’s reaction, or disrupting the schedule, you have a culture problem that no written policy can fix.
2. Near-misses get the same attention as actual incidents. Most practices are good at responding when something goes wrong. Far fewer are good at responding when something almost goes wrong. But near-misses are gifts. They reveal system vulnerabilities before a patient is harmed. Track them. Discuss them. Fix the underlying cause.
3. Safety isn’t a project. It’s how the practice operates. Accreditation standards aren’t a checklist you complete once and file away. Practices that thrive treat their policies and procedures as living documents that evolve as the practice learns. When you do a timeout before a procedure, it shouldn’t feel like a regulatory box to check. It should feel like the most natural thing your team does.
Practical steps you can take this month
You don’t need to overhaul your entire practice overnight. Start with these:
- Conduct a simple safety huddle. Before your first procedure each day, spend two minutes with your team reviewing the schedule, flagging any concerns, and confirming equipment readiness. This alone can prevent a surprising number of issues.
- Pick one adverse event category and build a tracking system. It doesn’t need to be sophisticated. A shared spreadsheet or log where your team records incidents and near-misses (with no blame attached) creates the raw material for quality improvement. Focus on one area first. Medication events, equipment failures, or patient falls are common starting points.
- Review your emergency protocols with your team, out loud. When was the last time your staff actually walked through what happens if a patient has a malignant hyperthermia reaction, or an anaphylactic event? Knowing where the crash cart is located is different from having practiced the response. Tabletop exercises, even informal ones, expose gaps you won’t find on paper.
- Audit your informed consent process. Do patients truly understand the risks of office-based procedures, or are they signing forms in a rush? Informed consent isn’t just a legal shield, it’s a safety tool. When patients understand what to expect, they’re better partners in their own care.
The power of educational accreditation
Every accrediting organization will evaluate whether your practice has a functioning quality and safety infrastructure. Surveyors aren’t just looking for policies in a binder. They’re looking for evidence that those policies live and breathe in your daily operations.
The practices that struggle most during surveys have built their documentation in a vacuum, disconnected from how the practice actually runs. The practices that do well have staff members who can describe their safety protocols from memory, because they use them every day.
These are universal truths, regardless of which accreditor you choose. But as you consider your options, keep in mind that a purely evaluative survey experience can feel adversarial, especially for a practice going through accreditation for the first time. An accreditation experience that’s built around education will leave your team stronger on the other side, with a clearer understanding of why each standard exists and how it fits into the way your practice already works.
That’s the approach ACHC takes. Our surveyors are experienced clinicians, and they’re trained to teach during the survey, not just score. For a physician-led office weighing accreditation for the first time, that difference shows up in the post-survey debrief and in how confidently the team runs the practice the following Monday morning.
None of this changes the work you need to do internally to build a strong safety culture. But it does mean the accreditor you partner with can either reinforce that culture or complicate it.
Further reading
For a deeper dive into safety culture in office-based surgery settings, including specific strategies for integrating quality assurance and performance improvement (QAPI) into daily operations, explore these resources:
Accreditation deadlines in Alabama require applications by January 31, 2027. If you’re exploring your options, learn more about ACHC’s OBS Accreditation Program.
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