1. JCAHO Accreditation/Survey Process for Ambulatory Surgical Center (ASC) By F O HSCI 547 Fourth Assignment

2. Focus of Accreditation Process ASC is committed to highest level of patient safety and care. ASC has met the highest & most rigorous performance standards. ASC provides a safe environment for patient’s care. ASC protects patient’s rights. ASC protects patient against infection. ASC plans for emergency situations.

3. Pre-Survey Process ASC receives from JCAHO access to Periodic Performance Review (PPR) & output of Priority Focus Process (PFP) on how to proceed for next survey. ASC has 3 months to complete PPR. ASC develops a plan of action with measures of success (MOS) if required. JCAHO reviews plan of action & informs ASC of results. ASC completes application for accreditation 9 months before next survey. JCAHO provides output of PFP to ASC 2 weeks before survey.

4. Survey Process: On-site Survey Survey is conducted by one JCAHO surveyor for 2 days. Survey includes following: - Opening conference, - Tracer activities, - Observation of center’s administrative and clinical activity, - Assessment of physical facilities & patient care equipment, - Leadership exit conference.

5. ASC Survey Agenda On-site survey agenda is developed based on information gathered about ASC. Agenda is customized to fit needs & services. First Day Agenda will cover: - Opening conference: surveyor will receive list of active patients, organization chart, list of board of directors, statement of conditions, care management plans, policies/procedures for credentialing, performance improvement data.

6. ASC Survey Agenda (cont’d.) - Review of PFP process, MOS from 18-month PPR, plans for improvement, review of PI & infection control, select patients for tracers & conduct tracer activity. - Discussion with leadership critical systems analysis. Second Day Agenda will cover: - Discussion with staff regarding management of medication, infection control issues, & use of data for improvement purposes. - Review of environment of care plans including building tour for Life Safety Code. - Surveyor conducts HR & credentialing review. - Surveyor prepares report & conducts CEO exit briefing & organization exit conference.

7. Post Survey ASC has 45 days following Accreditation Report to submit Evidence of Standards Compliance (ESC). ASC will be moved to “Accredited” status if at end of 45 days it successfully addresses requirements for improvement. ASC may be moved to “Provisional Accreditation” status if ESC is not completely approved. JCAHO makes available on its web site Quality Report on ASC.

8. Additional Activities/Processes Business Associate Agreement: -This agreement is signed prior to going through a survey. -The signing of this agreement between JCAHO & ASC will allow both parties to exchange information and be in compliance with requirements under HIPAA & allow accreditation process to continue without disruption.

9. Additional Activities/Processes (cont’d.) Statement of Conditions (SOC): -SOC is required if ASC participates in Medicare Program. -ASC requesting deemed status survey should complete SOC. -This document helps ASC to do a critical self-assessment of its current level of compliance with Life Safety Code & describe how to resolve any deficiencies.

10. Additional Activities/Processes (cont’d.) CMS Conditions of Coverage (CFC): -ASC must meet CMS requirements for Conditions for Coverage in -ASC requesting deemed status survey should complete SOC. -This document helps ASC to do a critical self-assessment of its current level of compliance with Life Safety Code & describe how to resolve any deficiencies.

11. Additional Activities/Processes (cont’d.) Deemed Status Survey: -JCAHO will conduct unannounced survey per CMS requirement. -Survey will be conducted to evaluate compliance with both JCAHO standards and CMS conditions for coverage. -ASC must complete Statement of Conditions.