Office-based surgery (OBS) centers are an attractive choice for patients seeking surgery outside the hospital setting. Not only are these centers providing quicker access to scheduling and lower out-of-pocket costs, but also they are increasing the variety and complexity of cases being performed in the office-based setting.

With the growth comes the need for regulation, and many states are now implementing regulatory requirements for OBS centers based on the levels of sedation used.

Yet amid the growth and regulation, one thing that does not change based on the setting for procedures and surgeries is that patient safety must come first.

Essential Considerations

When thinking of patient safety in your OBS, consider the following:

• Patient selection (comorbidities)
• Environment
• Procedure/surgical risk and anesthesia risk
• Recovery and safe discharge
• Tracking and trending of QAPI data

The Accreditation Commission for Health Care (ACHC) Standards listed below apply to the safety requirements for office-based surgery centers. Be sure to review ACHC’s 2022 OBS Standards Manual for the full standard requirements.

Standard 02.01.10: Assessment of Staff Competency

The organization must have an objective process for assessing the competency of each staff member.

Competency is performed at least annually and at intervals as defined by the organization.

Competency assessments are based upon written criteria addressing crucial elements of the job the employee routinely performs.

Standard 03.00.03: Professional Staff: Policies

For patient safety and quality of care, the organization ensures that individuals who provide professional services are working within their scope of practice, are privileged, and meet appropriate professional standards.

Standard 04.00.01: Quality Assessment and Performance Improvement

The organization must develop, implement, and maintain an ongoing, data-driven Quality Assessment and Performance Improvement (QAPI) program that demonstrates measurable improvement in patient health outcomes and improves patient safety by using quality indicators or performance measures associated with improved health outcomes.

Standard 10.01.01: Verification Process

The organization adopts written policies and procedures that include the use of standard procedures to ensure proper identification of the patient and procedural site to avoid wrong patient/wrong procedure/wrong site errors.

Standard 11.00.01: Anesthesia and Sedation Levels

The organization identifies eligible anesthesia and sedation providers in accordance with the governing body’s approved scope of procedures and levels of anesthesia, sedation, and analgesia.

The organization identifies providers for all anesthesia and sedation levels in accordance with government regulations and scope of practice.

Propofol may be administered only by an anesthesia professional.

The organization has policies determining the procedures appropriate for moderate sedation.

Standard 12.00.07: Safe Administration Practices

The organization has policies and procedures supporting safe medication administration practices.

The administration of medications reflects standard practices for patient safety, such as the U.S. Centers for Disease Control and Prevention (CDC).

Standard 15.00.01: Environment

The organization must have a safe and sanitary environment, properly constructed, equipped, and maintained to protect the health and safety of patients.

The organization must comply with requirements governing the construction and maintenance of a safe and sanitary physical plant, safety from fire, emergency equipment, and emergency personnel.

Standard 15.02.01: Emergency Equipment and Supplies

The professional staff and governing body of the organization coordinate, develop, and revise organization policies and procedures to specify the types of emergency equipment and supplies required for use in the procedure room.

The equipment must meet the following requirements:

• Be immediately available for use during emergency situations.
• Be appropriate for the organization’s patient population.
• Be maintained by appropriate personnel.

Tips for Patient Safety and Compliance with Standards

Training and planning will help your organization achieve and maintain accreditation and provide a safety-focused environment for your patients.

• Develop a safety checklist for each phase of care and the environment.
• Anticipate critical events and perform simulated drills with staff.
• Ensure your emergency equipment is functional and the checklist is completed before procedures and surgeries are performed.
• Confirm education, training, and competency evaluation are up to date for the individuals providing care.
• Review your facility’s policies and procedures to ensure they reflect your current practices.
• When moderate sedation or higher is used, ensure at least one person in the procedure room is certified in Advanced Cardiovascular Life Support (ACLS).

Dedication to achieving and maintaining accreditation through Accreditation Commission for Health Care (ACHC) reflects the commitment of an office-based surgery center’s leadership and staff to creating a culture of safety.

Here to Help

We are here to help. If you have questions or wish to access the most recent ACHC Office-Based Surgery Accreditation Standards Manual, contact your Account Advisor or email us at [email protected].