Top ASC Deficiencies Highlight Opportunities for Improvement
By: Rommie Johnson, MPH, PMP, Program Director
Rommie Johnson manages the strategic and programmatic direction for Ambulatory Surgery Centers (ASC) and Office-Based Surgery (OBS) Centers 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.
Posted: November 4, 2025
Data from the latest Quality Review edition of Surveyor show that operational challenges remain for ambulatory surgery centers. In the recent reporting period, 14 standards were found noncompliant in more than 25% of surveys conducted for ACHC ASC Accreditation. Examples of findings from top deficiencies range from a lack of documentation to failing to address sanitation issues or assess data security risks.
The three most commonly cited standards—03.01.02 Credentialing Files, 05.00.06 Sanitary Environment, and 08.00.03 Form and Content of the Medical Record—also topped the list last year, underscoring persistent opportunities for improvement in areas essential to patient safety and quality of care.
Overall, frequent deficiencies from ASC surveys highlight an ongoing need for consistent documentation practices, enhanced attention to details, and broader staff engagement supported by effective education and training.
New this year
Continuous improvement is woven into all we do at ACHC, including the annual Quality Review edition of Surveyor. In our recent issue, “tips for compliance” under each standard profile are enhanced to address varying levels of accreditation knowledge and experience across your agency. Explore our new Accreditation Nerd categories to see which is best for you.
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