Practice must take measures to reduce risk
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The Joint Commission on Accreditation for Healthcare Organization’s requirements for physician offices and ambulatory settings that practice invasive procedures, which involve sedation, include the following areas of emphasis: Ambulatory accreditation under the office-based surgery standards is intended for providers performing operative or invasive procedures in an office setting. Organizations licensed as ambulatory surgery centers (ASCs) are surveyed under the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC).
Organizations seeking Medicare certification through Joint Commission accreditation must be surveyed under the CAMAC. Organizations that may recover more than one patient over-night at a time must be surveyed under the CAMAC. Hospital-based organizations are surveyed under the Comprehensive Accreditation Manual for Hospitals.
Practices must meet all the following criteria to be eligible for accreditation under the office-based surgery standards:
• The organization or practice is composed of three or fewer surgeons (physician, dentist, or podiatrist) performing operative or invasive procedures.
• The organization or practice must be surgeon-owned or operated, for example, a professional services corporation, private physician office, or small group practice.
• Invasive procedures are provided to patients. (Practices only providing procedures such as excisions of skin lesions, moles, and warts and abscess drainage limited to the skin and subcutaneous tissue are not typically surveyed under office-based surgery standards.)
• Local anesthesia, minimal sedation, conscious sedation, or general anesthesia are administered. Office-based surgery practices that render four or more patients incapable of self-preservation at the same time are required to meet the provisions of the Life Safety Code. Practices may work with the Joint Commission to identify equivalencies to meet these requirements.
Other key practice standards
PC.6: The practice takes action to prevent or reduce the risk of nosocomial infection in patients, staff, and visitors.
PC.6.1: The practice takes action to control outbreaks of nosocomial infections when they are identified.
Intent of PC.6 and PC.6.1
Infection control processes and procedures are designed based on current scientific knowledge, accepted practice guidelines, and law and regulation. At a minimum, defined protocols and schedules for infection control in the procedure and recovery areas include the following:
• Only authorized and properly attired staff are allowed in procedure areas.
• Suitable equipment and cleaning agents are provided for regular cleaning of all interior surfaces.
• Suitable equipment is available for rapid and routine sterilization of procedure room materials.
• Sterilized materials are packaged and labeled in a consistent manner to maintain sterility.
• Anesthetic apparatus is inspected and tested before each use by the practitioner who will administer the anesthetic. If found defective, the equipment is not used until the fault is repaired; repair of the equipment is documented.
• All individuals in procedure areas use acceptable aseptic techniques.
• Appropriate ventilation and humidity control are provided to minimize the risk of infection and provide for the patient’s safety.
• Procedure areas are appropriately cleaned after each procedure.
• Provision is made for use of isolation precautions or, when indicated, for immediate transfer when patients are known or suspected to have an infectious disease.
• Temperature control for sterilizers, refrigerators, and other machines are monitored.
• A preventive maintenance schedule is established and maintained that includes periodic calibration, cleaning, and adjustment of all equipment, as appropriate.
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