Proactive Rounding Strengthens Office-Based Settings

By Cyndi Newman, MSHL, BSN, RN, Senior Clinical Review Specialist

Cyndi Newman is an ACHC Senior Clinical Review Specialist for office-based surgery and ambulatory surgery centers. She has over 30 years of experience as a registered nurse, surveyor, and risk manager. Cyndi is passionate about quality patient care and the collaborative nature of accreditation.

Posted: May 12, 2026

In any procedural setting, environmental rounding is a critical tool for compliance with patient safety, infection prevention, and ACHC Office-Based Surgery Accreditation Standards. Rounding may seem overly formal for an office-based surgery practice, but it represents an intentional effort to proactively identify physical hazards, needed repairs, and potential sources of infection. The goal of environmental rounding is to minimize risk to your patients, staff, and practice this year and beyond.

Surveyor findings based on observation

Deficiencies noted by ACHC Surveyors include:

  • Chipped paint on walls.
  • Compromised integrity of doors to procedural spaces/ORs. 
  • Waste on the floor instead of being contained in a receptacle.
  • Overflowing linen carts or carts without a lid.
  • Upholstery or OR mattress pad tears, exposing the foam. 
  • Rust on equipment.
  • Dirty or stained cubicle curtains.
  • Hallway clutter.
  • Stained and broken ceiling tiles.
  • Corrugated boxes.
  • Expired patient supplies.
  • Water intrusion.
  • Food/drink in clinical areas.

Each of these items is directly observable and therefore avoidable. In 2026, make rounding an integral part of your routine monthly processes. 

Relevant standards

Multiple ACHC Standards address requirements for the procedural environment. Here are a few examples:

05.00.06 Sanitary Environment

The organization must provide a functional and sanitary environment for the provision of services by adhering to professionally acceptable standards of practice.

The organization’s environment of care is maintained to avoid sources and transmission of infections and communicable diseases.

All areas of the organization must be clean and sanitary. This includes:

  • Waiting area(s).
  • Pre-procedural prep area(s), the recovery room(s).
  • Operating or procedure rooms.
  • Sterile processing areas

The organization must appropriately monitor housekeeping, maintenance (including repair, renovation, and construction activities), and other activities to ensure a functional and sanitary environment.

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.

15.00.02 Physical Environment

The organization must provide a functional and sanitary environment for the provision of procedures.

The organization must be designed and equipped to provide safe, efficient, high-quality ambulatory healthcare services.

The physical premises of the organization and the surrounding areas used by patients (including at least all stairwells, corridors, and passageways) must meet the functional requirements listed in this chapter, including:

  • The organization’s procedural spaces are appropriate for the type of surgery performed.
  • The organization has the right kind of equipment in these spaces for the types of surgery it performs.

15.03.02 Facility Maintained Clean and Orderly

The interior of the facility, the exterior of the physical structure housing the organization, and the exterior walkways and parking areas must be clean, orderly, and maintained free of any defects that are a hazard to patients, personnel, and the public.

  • Organizations located in multiple-use buildings are responsible for communicating problems to the management of the building.
  • There must be policies and procedures relating to the description and scope of housekeeping services.

Tips for compliance

  • Set aside time for routine rounding.
  • Use a checklist.
  • Take notes and manage corrective actions.
  • Ensure staff have access to and are familiar with environmental and infection control policies and procedures.
  • Share findings with the QAPI team and governing body.
  • Include staff in rounding; infection prevention is everyone’s job.

Key benefits

  • Infection prevention: Regular rounding helps identify potential sources of infection, such as mold, dust, rust, expired supplies, improper storage of sterile equipment, and inadequate disinfection of high-touch surfaces.
  • Risk reduction: Regular rounding identifies structural hazards, damaged equipment, or safety issues that could harm patients or staff.
  • Compliance: Regular rounding ensures your organization is prepared for surveys by checking compliance against ACHC Standards.
  • Staff assessment and education: Regular rounding allows for real-time assessment of staff practices, including infection control, hand hygiene, use of PPE, and handling of patient supplies.
  • Patient satisfaction: Regular rounding includes consideration of a patient’s perspective on the cleanliness and condition of the organization. This directly correlates to patient satisfaction surveys.

Resources

The CDC and APIC each offer resources you may find helpful for your environmental rounding and ICP program: 

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