JCAHO Accreditation/Survey Process for Ambulatory Surgical Center (ASC)

1
JCAHO Accreditation/Survey ProcessforAmbulatory
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 patients
  care.
• ASC protects patients 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 centers 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 (contd.)

• - 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.

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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.

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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.

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Additional Activities/Processes (contd.)

• 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.

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Additional Activities/Processes (contd.)

• 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.

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Additional Activities/Processes (contd.)

• 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.