Policies and Procedures Guide OBS Practices

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

Tricia Dixon-Thomas is a clinical review specialist for the Office-Based Surgery (OBS) and Ambulatory Surgery Center (ASC) Accreditation Programs at ACHC. She is passionate about teaching and mentoring the next generation of outstanding managers and directors in the outpatient surgical environment.

Posted: March 3, 2026

A cornerstone of achieving and sustaining excellence in office-based surgery is the development of comprehensive, well-organized policies and procedures that align with ACHC Accreditation Standards. These documents serve as essential guides for staff in their daily activities, keeping patient safety, operational consistency, and compliance with ACHC Standards top of mind.

Accreditation and standards

ACHC Office-Based Surgery Accreditation operates on a three-year cycle. During the initial and renewal application process, organizations submit their policies and procedures, which ACHC reviews before the onsite survey. Typically, an OBS survey is conducted within three to seven months of application. If any deficiencies are found, the office-based surgery practice provides a plan of correction (POC), which must be approved by ACHC prior to granting accreditation.

ACHC OBS 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 OBS practice. 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 plan must identify relevant quality indicators, define data collection methodologies, outline corrective actions, and designate oversight responsibilities. It is a forward-looking document. Additionally, policies should mandate an annual quality report that retrospectively 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 procedure room temperature, humidity, and airflow following 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 require an H&P and identifying acceptable time limits 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 policy reviews are essential to supporting compliance with ACHC Standards. Documentation of leadership oversight and corrective actions should be kept as evidence of continuous quality improvement.

Avoiding common pitfalls

The use of generic quality indicators, incomplete documentation, delayed implementation of corrective actions, and ambiguous H&P requirements may lead to accreditation survey findings. Robust policies closely aligned with ACHC OBS Standards enhance preparedness, improve patient safety, and promote operational efficiency.

By developing and maintaining thorough, ACHC-aligned policies and procedures, OBS 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 practice for long-term success in delivering safe, efficient, and patient-centered care.

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