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Don’t Let Contractors Sink Your Surgery Practice: OBS Vendor Oversight and QAPI Integration, Part 2

By: Rommie Johnson, MPH, PMP
Program Director

Posted: November 3, 2025

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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.

When you run an office‐based surgery (OBS) practice, balancing overall management with care delivery details is an ongoing challenge. One big picture requirement that often slips under the radar is oversight of contracted services. This two-part article covers why oversight of contractors is crucial and offers clear action steps to build and sustain compliance.

Be sure to read Part 1, which focuses on proactive planning. Part 2 (this article) outlines how to implement improvements and monitor ongoing performance.  

Once you have set up a system to track the vendor contracts you manage, it’s time to do more. The use of contractors is usually tied to cost savings, efficiency, and focused expertise. You can also use these vendors to improve the overall sustainability of your office-based surgery practice by engaging them in your Quality Program. 

Improving vendor oversight

The three tips below take your contractor oversight to the level of engagement that drives measurable, sustainable improvement.   

1. Incorporate contractors into your QAPI meetings.

Embedding review of contractor metrics into your QAPI agenda proves to ACHC OBS Accreditation Surveyors that the governing body actively oversees each service. Regular review also fosters continuous improvement—catching issues before they escalate.

Action: At each monthly or quarterly QAPI meeting:

  • Review performance data.Present the latest KPI results for each contractor.
  • Identify trends or deficiencies: For example, if linen service fails to meet on‐time delivery targets more than twice in a quarter, that flags a need for corrective action.
  • Assign follow‐up tasks: Decide who on your team will reach out to the vendor for improvement plans, document any required retraining, and set deadlines.

2. Establish a formal process for corrective action.

A documented corrective‐action loop shows accrediting bodies that you’re not merely “awareness‐checking” contractors—you’re demanding and verifying improvement.

Action: When a performance metric falls short (e.g., cleaning crew misses two consecutive ATP swab targets), follow this process:

  • Document the deficiency: Include the date, service, and specific KPI missed.
  • Notify the vendor in writing: Specify the gap (e.g., “Three of five ORs failed ATP swab in April 2025.”) and request a corrective action plan within five business days.
  • Review the vendor’s plan: Ensure that the proposed correction plan addresses root causes (e.g., “crew understaffing on Tuesdays”) and includes realistic remediation steps.
  • Confirm follow‐through: Check subsequent performance data. If the vendor remains out of compliance, consider alternative providers or adjust contract terms.

3. Automate reminders.

Small practices can’t rely on paper alone. A one‐time investment in setting up calendar reminders frees mental bandwidth. When your surveyor asks, “When did you last review your contracted anesthesia provider’s credentials?” you’ll have a time-stamped reminder that popped up, ensuring you performed the check. 

A quick calendar alert prevents lapses without cluttering your inbox. If you delegate tasks to an office assistant or nurse, share calendar invites so they’re equally accountable. 

Action: Use free or inexpensive calendar tools, such as Google Calendar or Microsoft Outlook, to set reminders for:

  • Annual credentialing check: “Verify anesthesia licenses.”
  • Quarterly check‐in: “Review contractor inventory.”
  • Contract renewal alerts: “Contact ClinicClean 30 days before contract expiration.”

Key takeaways for OBS leaders

Choosing to become accredited is a clear statement about your commitment to quality. Maintaining compliance establishes the culture of quality within your organization that makes it sustainable. Don’t let external contractors inadvertently derail your efforts. Establish your expectations upfront, measure ongoing performance, and take action for correction when it’s warranted.  

  • Maintain a centralized contract inventory with clear KPIs.
  • Embed contractor performance into your QAPI Program.
  • Regularly verify credentials and training of all contracted clinicians.
  • Follow a formal corrective action process for any substandard performance.
  • Document every step so that, during your next ACHC Accreditation survey, you’ll have evidence of active oversight—not just good intentions.

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Discover more articles about Office-Based Surgery Accreditation.