If there’s one guiding philosophy for surgery centers undergoing accreditation to follow, it is this: It takes teamwork.

“It takes more than one person to prepare for accreditation,” says Lori Callahan, MBA, CASC, director of Algonquin Road Surgery Center in Lake in the Hills, IL. Callahan would know. She’s personally been through five successful Joint Commission surveys since the surgery center opened in 2002. Here are her best practice strategies:

  • Compare policies to Medicare standards.

“We look at our policies to see if we’re following Medicare standards,” Callahan says. “We also involve leadership so they’re aware of the accreditation process, and we seek approval from the board.”

The Joint Commission’s own standards mirror Medicare’s standards in all areas, including life safety, human resources, infection control, and leadership.1,2

Organizations can include references to both CMS’ and The Joint Commission’s standards. This will provide a cross-reference and a way to look up their own policy and procedures when they get notice from CMS or The Joint Commission that one of their standards has been amended. “So, say we took medication management, and the quality director comes in and reviews the medication manual, taking our policies and working with our medication manager onsite,” she explains. “The quality director says, ‘Here are the standards we have to do, so are you doing these, and are your processes still working?’”

The same process is repeated for infection control through the infection control officer, and for other areas. “You read the chapter, look at the policies, and see where there are discrepancies,” Callahan says. “The quality manager will go in and make changes, tweaking the policies and submitting them back to the board.”

If an ambulatory surgery center (ASC) is lucky, it will get through all the chapters within a year, she adds.

All policies and procedures are given to the center’s leadership to read and make sure processes adhere to the policies and standards.

  • Include adherence to standards when performing staff reviews.

ASCs can change their employees’ evaluation form to reflect the person’s adherence to standards.

Going through the accreditation process can highlight an ASC’s problem areas, such as where employees are slacking on processes.

By including their compliance to standards in their annual reviews, an organization can ensure this will be a priority. The employee review would compare the staff member’s job title to specific policies, as well as general quality measures, such as showing up on time and attending staff meetings, Callahan says.

These standards could include having all documentation completed and signed, following infection prevention protocols, obtaining informed consent signatures on time, avoiding errors, and properly handling errors when they occur.

  • Learn from mistakes discovered during survey.

“Our biggest surprise in a survey involved ultrasound for pain blocks,” Callahan notes.

The disinfection process was not adequate. There were not enough ultrasound transducers to make available a disinfected machine at all times. Processing these can take 20 minutes, she says.

“We wanted to eliminate the possibility of shortcuts, so we bought more to make sure people were following the disinfection process correctly,” Callahan says.

With three transducers and one ultrasound, there always is a disinfected machine available.

“We had to re-educate and read the entire manual and find a high-level disinfectant,” she recalls. “It changed our entire process on how we do the blocks. Our findings were that we had to go in and find more transducers and educate everybody more fully before we could do this process, so we stopped using the ultrasound for about a month while changing the process.”

The ASC brought in new products, created a new process, and asked for the assistance of manufacturer representatives.

“We educated the staff members, who would be in charge of the high-level disinfectant, and we educated the anesthesia team,” she says. “This took a while, but now everyone knows the process, and everyone is well educated.”

Any citation a surgery center receives means there’s a higher level of risk to patients, and the center has to stop carrying out that process and come up with an alternative plan. The plan might include education and changing practices to meet the standard, Callahan explains.

As a result, the surgery center’s corrections and new processes were so thorough, the surveyor asked if it could be included in The Joint Commission’s best practice library.

  • Look for outliers.

“We benchmark everything and look for trends,” Callahan says. “As soon as we see something that looks like an outlier, we review it.”

For example, one year there were four or five cases of deep vein thrombosis (DVT). “So, we went back and reviewed every DVT,” she says.

They found there were cases involving young women on birth control medication and older people, and there was no single cause.

“Our goal is to have zero DVTs, so we decided to do a better job of education, reminding patients to do exercises when they’re on their phones and to walk and move around after surgery,” Callahan explains.

“We educated patients, and reached out to physicians, and did a 30-day follow-up on patients to make sure there were no more DVTs.”

The education focus appeared to work, as there were no DVTs the following year, she adds.

As general advice for accreditation survey preparation, Callahan recommends ASCs use the education tools and information the accreditation organization provides.

“You could attend their boot camps, read their manuals, and get a team involved,” she says. “You can have a breakfast series every month for the staff, educating them for an hour on a certain topic, or there are webinars you can use.”

A surgery center will experience better outcomes when engaging staff to be involved in the process through education, reading, and providing suggestions.

“If you just come in and say, ‘Hey, do this,’ you’ll get a lot of pushback,” Callahan says. “It’s all about improving patient care to be the best we can be and making sure you have staff that feel empowered.”


  1. Centers for Medicare & Medicaid Services. Conditions for coverage and conditions of participations. Available at: https://go.cms.gov/2I2Qevf. Accessed May 2, 2018.
  2. The Joint Commission. Great achievements come one step at a time. Deemed status for ASCs seeking Medicare certification. Available at: http://bit.ly/2rejipX. Accessed May 2, 2018.