Developing Comprehensive ASC Policies and Procedures

By Tricia Dixon-Thomas, MSN, RN, Clinical Review Specialist

Tricia Dixon-Thomas is a clinical review specialist for the Ambulatory Surgery Center (ASC) and Office-Based Surgery (OBS) Accreditation Programs at Accreditation Commission for Healthcare (ACHC). With more than 20 years of experience in ASCs, she is passionate about teaching and mentoring the next generation of outstanding managers and directors in the outpatient surgical environment.

Posted: March 3, 2026

Earning ACHC Accreditation signifies an ambulatory surgery center’s dedication to patient safety, regulatory compliance, and operational excellence. A cornerstone of achieving and sustaining accreditation is the development of comprehensive, well-organized policies and procedures that align with ACHC Standards. These documents serve as essential operational guides for staff in their daily activities and as evidence of compliance during surveys.

Accreditation and standards

ACHC ASC Accreditation operates on a three-year cycle. During the application process for new and renewing accreditation, facilities are required to submit their policies and procedures, which ACHC reviews before the onsite survey.

ACHC Standards function as both a regulatory framework and a roadmap for continuous quality improvement. Instead of focusing solely on compliance, standards promote proactive planning, consistent implementation, and active leadership oversight. Policies and procedures drive the what and the how for your ASC. Getting these foundational documents right sets up an organization for consistent, efficient, and intentional patient care.

Key policy requirements

  • Quality assessment and performance improvement (QAPI): Policies should require an annual written QAPI plan that is formally approved by the organization’s leadership. This prospective plan must identify relevant quality indicators, define data collection methodologies, outline corrective actions, and designate oversight responsibilities. Additionally, policies should mandate an annual retrospective quality report that summarizes activities, findings, and outcomes.
  • Medication safety: Medication management policies must address tracking of controlled substances, safe preparation and administration, and clearly defined medication order requirements. Comprehensive documentation covering receipt, storage, administration, and disposal of medications is essential for compliance and safety.
  • Surgical time-out and pre-procedure verification: Policies must require a documented surgical time-out prior to incision. Procedures verify patient identity and the procedure, surgical site, consent, and availability of necessary equipment. This process is integral to ensuring patient safety and preventing errors.
  • Environmental controls: Policies should require daily monitoring and documentation of operating room temperature, humidity, and airflow in accordance with recognized standards. Clear procedures for corrective actions in response to out-of-range readings must be established and communicated to staff.
  • Medical history and physical (H&P): Policies should establish a risk-based approach to H&P requirements, clearly specifying which patients or procedures necessitate an H&P and identifying acceptable time frames for completion.

Policy and procedure manual

A well-structured policy and procedure manual enhances usability and survey readiness. Each section should include clear policy statements, detailed procedural steps, designated accountability, and specified review frequency to ensure continual relevance and compliance.

Ongoing staff training, regular audits, and annual reviews are essential to maintaining compliance with ACHC Standards. Documentation of leadership oversight and corrective actions should be maintained as evidence of continuous quality improvement.

Avoiding common pitfalls

Common accreditation pitfalls include the use of generic quality indicators, incomplete documentation, delayed implementation of corrective actions, and ambiguous H&P requirements. Robust policies that are closely aligned with ACHC Standards enhance regulatory preparedness, improve patient safety, and promote operational efficiency.

In an evolving healthcare landscape, ASCs must continually adapt to changing standards and expectations. By developing and maintaining thorough, ACHC-aligned policies and procedures, healthcare providers demonstrate regulatory compliance and establish a foundation for high-quality patient care and operational excellence. A proactive approach to policy development—supported by ongoing education, regular review, and leadership engagement—ensures readiness for accreditation and positions your ASC for long-term success in delivering safe, efficient, and patient-centered care.

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