Operating Room Accreditation

OBS Credentialing has over 40 years of combined experience and will recommend the appropriate accrediting agency for your OBS (AAAASF, AAAHC & JCAHO).

Health care organizations establish their own internal standards and rules of operations for their facilities. Accreditation ensures that the facility’s rules of operation meet the regulations and standards set by governing bodies. The Center for Medicare & Medicaid Services (CMS) governs the accreditation for ASCs. CMS does not govern OBSCs.

• The Accreditation Association for Ambulatory Health Care (AAAHC) is a private accrediting organization that encourages and assists ambulatory health care organizations to achieve patient care in efficient and cost-effective ways. The AAAHC has focus and experience surveying and accrediting ASCs and OBSCs.
• The American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) is one of the largest private, not-for-profit outpatient accrediting organizations. The AAAASF was created by surgeons working in an OBS environment and is the agency of choice for OBS accreditation. “Quad-A” accreditation ensures facility compliance with the standards of professional training, operational safety, and the physical layout of the center.
• The Joint Commission is an independent, not-for-profit organization that accredits a wide range of health care facility modalities including office-based surgery. The Joint Commission accreditation process focuses on patient rights and education, infection control, and many more characteristics.

Medical Director

All 3 Accreditation entities require that there is a medical director for the facility. In most cases this is the primary surgeon or owner of the facility.

OBS Credentialing has deep knowledge of and familiarity with the most experienced and professional accreditation consultants. OBS Credentialing will recommend the consultant and agency who most closely matches your office or facility culture and requirements.

There is a broad range of service options for overseeing the accreditation process:

• If your nursing staff is experienced and capable, you may want to keep the process oversight internal, i.e. Nurse Manager.
• There are ‘nurses for hire’ who are experienced with all aspects of successful accreditations, and will work with you on an ‘a la carte’ basis if you do not require full service process oversight
• Some consultants offer online educational content, through scheduled conferences and online forms, policies, quality studies, required tasks and supporting documentation. They assign a supervising nurse to work with your staff, and ensure the implementation of the required policies and procedures.
• Full service consultants coordinate all aspects of the details involved. They will give you hands-on support throughout the entire process from initial site visit, equipment and supplies review, staff training, logs and charts review, binders and OR inspection; whatever is needed to complete your survey successfully. A full-service consultant will address every detail; your agenda, materials, your floor plan, tailoring your forms to satisfy agency requirements and survey prep for the date of your survey. They are costly, but they will oversee all aspects of the process and ensure compliance with mandated policies and procedures.

Maintenance

Accreditation is not a ‘once in a 3 year process’. It is ongoing, and there are myriad details and ever changing requirements involved in maintaining your OBS accreditation. Once your site is accredited, the processes and protocols that were required to achieve compliance must be integrated into your daily office routine. Regulating agencies will not only schedule follow up surveys, they will also make unannounced ‘spot checks’; you must be prepared for them. Maintaining accreditation requires discipline and routines which agencies will review during follow up surveys. Adhering to these standards and protocols protects your patient, your practice and the investment you made in achieving this goal.

In-house Staff support

If needed, due to staff turnover, structural changes or other considerations, an accreditation consultant can support your Nursing and Administrative staff with keeping your OBS compliance standards up to date, survey-ready and prepared for unannounced visits. They will compile the task list for your practice, train your staff and oversee the strategy for implementation. They can provide ongoing support and notify you of agency standards revisions, updates, changes, improvement initiatives and mandates.

Tips:

• Plan ahead. It can take up to 6 weeks to schedule an initial inspection, so submit the application while completing the construction renovation punch list
• Work with a consultant or a nurse who has experience with primary surveys. Ask him or her how many surveys they have done
• Go through the accreditation manual yourself and ensure that each point has been addressed; the inspector will go through each line of the manual and you should have too
• Make sure you are up-to-date on the most recent updates to the requirements. For instance, a recent change by AAAASF specifies that all narcotics have to be stored on premises in a lockbox.
• Ensure personnel files are complete with a signed DOP (Delineation of Privileges) even if there is only one physician.

Crash Cart

Part of the inspection by all 3 Accreditation Organizations will be to examine the crash cart. The most commonly used cart to stock these emergency medications is the Armstrong Emergency Cart however this does ot include all the emergency medication.

A great alternative is to buy and subscribe to the Banyan Kit. The Z-1000, or other stat-kit, is a self contained kit with all required emergency medications with the added advantage of automatic replacement when a medication expires. This is a great option as facility staff do not have to keep track of expiration dates as the kit is automatically replenished. There is even a flat surface for the defibrillator on the top.

Standard Equipment and Medication

Equipment and supplies:

• AED (automated external defibrillator) *
• Oral airways – all sizes *
• Nasal airway – all sizes *
• Laryngoscope handle and blades *
• Endotracheal tubes – various sizes and stylet * (6.5, 7.0, 7.5)
• Ambu bag *
• Suction machine *
• Oxygen source *
• CPR board *
• ACLS flowsheet *
• MH flowsheet *
• IV fluids – 2 bag (LR or NS)
• Emergency Cricothyrotomy Kit
• Surgical lube
• Laryngeal Mask Airways (LMA) sizes 3, 4, 5
• Non-rebreather oxygen mask
• Nasal Canula
• Nebulizer administration mask
• IV starter kit (20, 22 G IV catheter, ETOH pads, tourniquet, tegaderm, IV admin set)
• Suction tubing & Yankauer

Medications:

• Adenosine *
• Albuterol inhaler
• Albuterol Nebulizer
• Amiodarone
• Corticosteroid * – Dexamethasone
• Atropine *
• Diphenhydramine *
• Ephedrine
• Short acting b blocker * Esmolol or Labetalol
• Epinephrine *
• Flumazenil *
• Hydralazine
• Lidocaine Plain *
• Naloxone *
• Nitroglycerin SL tabs or paste *
• Phenylephrine
• Anti-convulsant * – Phenytoin or Midazolam
• Succinylcholine *

Malignant Hyperthermia Kit:

• Dantrolene – 36 vials
• Sterile water – 1,000 ml bags, X 2
• Sodium Bicarbonate 8.4%, 50 ml vials, X 4
• Calcium Chloride X2
• Dextrose 50%, 50ml vials, X 2
• Insulin (in medication refrigerator)
• Furosemide 10mg/ml, 4ml vial, X 2
• Lidocaine 2%
• Normal saline, 500 ml bags cold, X 3, (in medication refrigerator)
• 60 cc syringes, X4
• IV catheter starter kit
• Foley catheter kit
• Cold packs (additional Ice cubes in freezer)
• Mini-Spike dispensing pin X 5
• 16 Fr Nasogastric tube
• Irrigating bulb syringe X 2
• Mannitol 25%