7 top accreditation deficiencies for ASCs + frequency of citations


Fire and life safety code compliance presented the biggest challenge for ASCs during 2018 surveys, according to the "2019 HFAP Quality Review."

Seven requirements that were most troublesome for ASCs, ranked in order of citation frequency:

1. Ensure safety from fire and life safety code compliance.
Citation frequency: 41 percent

2. Conduct periodic review of the scope of services, and establish a process for reappraising medical staff privileges.
Citation frequency: 27 percent

3. The governing body may only grant clinicians privileges based on medical staff recommendations detailing the applicant's competence.
Citation frequency: 23 percent

4. Maintain a functional and sanitary environment for surgical services in all areas of the facility, in accordance with nationally recognized infection control guidelines.
Citation frequency: 23 percent

5. Preoperatively assess a patient's anesthesia risk and include it in medical record documentation, along with documentation that a physician completed the procedure.
Citation frequency: 23 percent

6. Using quality indicators, implement an ongoing program for reducing medical errors and improving patient outcomes.
Citation frequency: 18 percent

7. An ASC's governing body has formal responsibility for the medical staff.
Citation frequency: 14 percent


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