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Don’t Let Contractors Sink Your Surgery Practice: OBS Vendor Oversight and QAPI Integration, Part 1

By: Rommie Johnson, MPH, PMP
Program Director

Posted: September 5, 2025

When you run an office‐based surgery (OBS) practice, toggling between overall management and care delivery details is an ongoing challenge. One big picture requirement that often slips under the radar is governing‐body oversight of contracted services. Whether you hire an external cleaning crew, contract nursing support, or outsource anesthesia, these relationships must be formally managed.

This two-part article covers why oversight of contractors is crucial and offers clear action steps to build and sustain compliance. Part 1 focuses on proactive planning and Part 2 outlines how to implement improvements and monitor ongoing performance.

Contractor oversight goals in office-based procedural settings

Office-based surgery offers convenience for patients and providers, but these organizations run lean when compared to ambulatory surgery centers. With smaller spaces and fewer staff, OBS providers often rely on contractors for key services that impact patient care.

  • Patient safety and infection prevention

OBS suites are compact environments where even minor lapses in cleaning or equipment maintenance can lead to serious safety issues. If your cleaning service isn’t monitored for consistent sanitation practices, you risk post‐procedure infections that compromise patient outcomes and your reputation.

  • Regulatory compliance and accreditation

ACHC OBS Accreditation Standards require evidence that your governing body actively oversees contracted services. Failing to demonstrate this can lead to repeat deficiencies, delays in accreditation, and potential fines. In a recent finding, an ACHC Surveyor noted:

“The facility lacks documentation showing the governing body’s oversight of contracted services to ensure that these services are provided in a safe and effective manner. Facility cleaning, linen services, biohazard waste, and generator maintenance are all contracted, yet performance measures were never selected or reported to the governing body. This deficiency is a repeat occurrence.”

Without defined performance metrics or routine reporting, the governing body cannot verify service quality. This leads to sustained noncompliance, which is both costly and preventable.

Action items for OBS contractor management

Here are three practical steps to integrate your contractors into your Quality Assessment and Performance Improvement (QAPI) Program and demonstrate ongoing oversight:

1. Create and maintain a contract inventory.

A clear, “at‐a‐glance” list ensures no contracted service is overlooked during audits and that your governing body knows exactly which vendors to evaluate.

Action: Develop a spreadsheet (or simple database) listing every contracted service. Include columns for:

  • Contract name (e.g., “ABC Cleaning Co”).
  • Service type (e.g., “OR Cleaning,” “Anesthesia Support,” “Reception Staffing”).
  • Contract start/end dates.
  • Key contacts: Names and emails for each vendor’s account manager.
  • Performance metrics: Agreed‐upon KPIs (e.g., “room turnover time,” “infection‐rate targets,” “credential verification rate”).

2. Define and document performance measures.

Quantifiable metrics allow you to monitor contractor performance objectively, feed data into your QAPI Program, and present results to your governing body.

Action: For each contract, pick at least two measurable performance indicators. Document them in a Contractor Quality Plan that includes vendor signatures. For example, for:

  • Cleaning services: “Percentage of ORs cleaned within 30 minutes of case end.” “Monthly ATP swab test pass rate (target ≥ 95%).”
  • Nursing services: “Contract RN orientation completion rate (100% within first week).” “Annual competency assessments documented for 100% of contract nurses.”
  • Anesthesia services: “Timely submission of updated board‐certification documents.” “Anesthesia‐related adverse event rates < 1%.”

3. Verify credentials and training of contract personnel.

All professionals delivering patient care must meet your practice’s standards. Credentialing and privileging shields you from liability if a contracted clinician’s license lapses.

Store these files in a central “Contract Personnel Folder” (electronic or paper). During surveys, you should be able to pull up credentials for any contract nurse or anesthesia provider within minutes.

Action: For every contracted clinical service (nursing, anesthesia), ensure you have:

  • Current licenses: Check state licensing boards quarterly.
  • Orientation records: Document that each contract clinician completes your OBS orientation, including emergency protocols, equipment usage, and facility layout.
  • Ongoing education: Maintain records of annual competency checks, such as ACLS or specialty‐specific certifications.

Takeaways

These initial steps set you up for compliance with accreditation standards by establishing an easy way to audit your contracts, the expectations tied to performance, and the qualifications and competencies of those contractors who serve your patients.

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Discover more articles about Office-Based Surgery Accreditation.