The HFAP has released new environmental rules in its accreditation requirements for ASCs. The following are sample items from the new requirements:

  • “ASCs must also ensure, however, that the OR humidity level is appropriate for all of their surgical and anesthesia equipment, and that supplies which require a different level of humidity than that in the OR are appropriately stored until used.”
  • “Each operating room should have separate temperature control. Acceptable standards for OR temperature, such as those recommended by the Association of periOperative Registered Nurses (AORN) or the FGI, should be incorporated into the ASC’s policy.”
  • “Only the altered, renovated, or modernized portion of an existing system or individual component shall be required to meet the installation and equipment requirements stated in NFPA 99.”
  • “Each system must be evaluated for its potential impact on both the patients and the caregivers if the system should fail. Based on worst-outcome scenario of a failure’s impact, the system is assigned a category.”
  • “Therefore, a Risk Assessment is required for certain building systems that the organization has, based on a documented defined procedure. HFAP does not prescribe what format the Risk Assessment must follow, but NFPA 99-2012 recommends the following documents:
    • “ISO/IEC 31010 Risk Assessment – Risk Assessment Techniques;
    • “NFPA 551 Guide for the Evaluation of Fire Risk Assessments;
    • “SEMI S10-0307E Safety Guidelines for Risk Assessment and Risk Evaluation Process;
    • “Other formal process.”
  • “All Risk Assessments must be available for review during a survey. Only the following building systems are required to be evaluated for categories in a Risk Assessment:
    • “Gas & Vacuum Systems;
    • “Electrical Systems;
    • “HVAC Systems;
    • “Electrical Equipment;
    • “Gas Equipment.”
  • “The ASC’s medical staff and governing body must adopt written policies and procedures that address the specific types of emergency equipment that must be available for use in the ASC’s operating room.”
  • “The ASC must have qualified personnel capable of using all emergency equipment as necessary.”

For more information about the new standards, please visit: