Ambulatory Surgery Centers (ASC) and Surgical Suites (SS) need to remain up to date with regulations and standards. Remaining in constant compliance is not only vital for ensuring safe patient care, but also to vital for ensuring you remain licensed and accredited. As health care regulations and oversight call for more reporting and transparency, ASCs and SS want to be able to report near zero citations if at all possible. The public will be able to review such metrics in the near future.

There are several components that our consultants will review when completing quarterly
compliance visits:

1. Governing Body Oversight

Our consultants will review your policies and procedures to ensure they are meeting the standards. Are meetings capturing all of the necessary information? Are the processes being followed all the way through and reported appropriately?

2. All Committees

Our consultants will review all of the main departments, such as quality assurance, infection control, risk management, and safety (to include, Life Safety). Are they performing at optimal levels? We can help provide guidance to ensure for efficiencies in these committees to obtain maximal results in less man-hours.

Quality Assurance is paramount due in part that it is heavily regulated by both the accrediting bodies and CMS. Performance improvement studies need to be present along with the need to collect on-going data.

Infection Control requires that an infection control risk assessment has been performed annually and that an adequate annual infection control plan has been developed and is being utilized.

Risk Management is paramount to minimize risk to the patients, employees, and center. This committee needs to work in conjunction with all other committees to ensure that the center is functioning safely.

Safety is of the utmost importance. Our mission as surgical professionals is to ensure our patient achieve optimal outcomes. This committee’s focus is on how we treat our patients and the well-being of the center as a whole. Life Safety is mandated by CMS and comes with its own set of conditions for coverage. Our consultants can help you navigate through all of the regulations to ensure for a seamless operation (no pun intended!).

3. Medical Records

Our consultants will review a sampling of your medical records throughout the quarters to ensure that all standards for patient care are being met. This is especially important from a risk management perspective.

4. Provider Credentialing and Personnel Records

Our consultants will review your provider’s credentialing files to ensure completeness and that they are meeting the standards. The personnel files will also be reviewed. CMS and the accrediting bodies have very specific guidelines as to what needs to be present in the files. As this may be an arduous process, we can help be the extra set of eyes that are needed to ensure they are impeccable.

5. Physical Plant

Finally, our consultants will do a facility review while on-site. This helps you to identify areas for improvement and any evident safety issues. Our consultants have vast experience with inspections and can assist in ensuring your center is always inspection ready. For more information about our compliance programs please contact us today! Custom Surgical Consultants is here to help! Schedule a consultation today.

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