There is a new option for ambulatory surgery centers (ASCs) applying for certification for total joints and spine surgeries.

  • Certification is for ASC, but also considers facility competency and surgeons’ proficiency.
  • Doctors need to have performed 50 or more procedures annually in outpatient or inpatient settings.
  • ASCs must have performed 20 surgeries within the past 12 months prior to their application for certification.

The Accreditation Association for Ambulatory Health Care (AAAHC) has answered requests from ambulatory surgery centers (ASCs) regarding a certification for total joints and spine surgeries.

“AAAHC has received numerous requests from accredited organizations for this certification, which people requested as a market differentiator and also to inform their communities that total joint replacements are safe,” says Therese Poland, RN, BSN, MSN, senior vice president, accreditation services, AAAHC. “There has been a lot of media and publicity around how safe an ambulatory surgery center is. This is a good way to validate the standard of care in this specialty area. Why do total joint and spine surgeries in a hospital when you can have them done in an ASC in a day?”

The Joint Commission also has advanced certification for total hip and total knee replacement. The accreditation agency began accepting applications in 2015. In collaboration with the American Academy of Orthopaedic Surgeons (AAOS), the organization began to offer a combined advanced total hip and knee replacement certification on Jan. 1, 2019.1 After a soft launch in 2018, AAAHC revised its certification process and made a final launch in January 2019. The certification is for three years and is focused on patient outcomes.2

“During the soft launches, we identified ways to improve the program,” Poland says. “Since the January launch, we’ve gotten around 30 applications for certification. The organizations are working hard on coming into compliance with the standards and are getting ready for a survey.”

Certification is for ASCs, but the process considers surgeons’ proficiency as well as facility competency and proficiency. One of the requirements is a median requirement of 50 procedures for physicians. “The ASC physician median volume is 50 procedures annually. They can do the procedures in inpatient or outpatient [settings]. The focus is on surgeon proficiency,” Poland says.

Surgeons also need to meet rigorous credentialing requirements and complete annual CME requirements for total joint or spine procedures. The main requirements are as follows:

  • ASCs must be AAAHC accredited and in good standing;
  • ASCs must demonstrate that their surgeons perform a median volume of 50 procedures. If six surgeons work at a center, then three or more must perform a volume of 50 or more procedures;
  • Facilities must have completed a minimum of 20 procedures within their ASC in the 12 months prior to initiating their application.

Surveyors want to see evidence that all ASC staff who provide direct patient care can perform with proficiency. “We want to know that your nurses know how to care for these patients based on best care practices,” she says. “We want to see that post-op positioning is correct, for example.”

A surveyor will want to see that nurses can position patients in a way that does not cause dislodgement. Post-op positioning is important because dislodgement could result in the need for another total hip replacement. Surveyors also want to observe how employees interact with patients.

“Do they care? Do they engage patients and their support persons in the process?” Poland asks. “We want to know that the patient is an active participant in their care. We want that patient to be supported.”

The surveyor also will review the preadmission process through to the post-discharge process, including how the patient is followed up at seven days, 30 days, and 90 days. “We want to know that patient is given discharge instructions and being followed up and that the ASC is tracking patient outcomes such as unplanned transfers or readmissions,” Poland explains. “We want the surgery center to take ownership for the entire care continuum.”

Typically, it takes about six months for an organization to become ready for certification, but it is possible for a dedicated ASC to be ready in three months, Poland says. Once leaders submit their application, AAAHC works with the ASC to schedule a survey on a date that is convenient for the organization.

On the day of a survey, AAAHC surveyors leave the ASC with a preliminary report that lists deficiencies. The organization is responsible for working on correcting those deficiencies and submitting a plan for improvement within 30 days. This plan must include supporting evidence of compliance.

“Then, we’ll review that internally and give it to the accreditation committee for a decision,” Poland says. “They’ll make a decision, and we release it straight away. Usually, we turn it around that week.” AAAHC’s decision outcome is either for a three-year certification or non-certification.

There are several ways ASCs can prepare for the community engagement requirements for certification in total joints and/or spine procedures:

Engage with the community. “We like to see that an organization is doing community outreach,” Poland says. “We want to see how they’re engaging with their community.”

The first step in community engagement is to learn more about the target population. “We require surgery centers to identify or define their geographic community and that they understand their community needs,” Poland says. “It takes a village to care for one patient. By understanding your community’s services, it helps you identify your own gaps in care.”

For instance, the ASC might find that some patients cannot return home following same-day surgery because they do not know a reliable caregiver. When this happens, the ASC should be able to identify rehabilitation providers and home health agencies that could help fill that gap.

“We ask the organization to understand their community’s needs, beyond understanding which services are available in the community, and to understand their community’s demographics,” Poland explains.

Collect community demographics and other data. Health systems are required to collect data about their target populations and review this information at least annually. Surgery centers can find these reports online and use these to obtain some basic information about the community’s demographics, health issues, and care gaps.

Other sources of community information can come from local health department surveys of trends and census data that are broken down to the county/city level.

Connect with external partners to bridge care gaps. Once ASCs identify care gaps, they can form partnerships with local providers. “We want to see that the ASC has identified community needs and has external partners who can bridge those gaps,” Poland says. “For example, a partner could be a home health agency or rehabilitation provider or physical therapy provider,” she says.

Surveyors want to see that the organization can identify a good partner, keeping in mind its own mission, vision, philosophy, and contracted service mission. “If you want to partner with a skilled nursing provider [SNP], then you need to know that the SNP has low infection rates,” Poland says. “If you want to know their satisfaction rates, then look at their patient reviews online. Do your due diligence and check out patient outcomes and patient feedback.”

Surgery center staff also should provide input on various potential community partners. “Ask about the provider’s responsiveness. If they’re rude to your staff on the phone, then they could be rude to their customers,” Poland suggests. “We sometimes forget about customer service. We want to make sure that’s consistent with our philosophy.”

Create tools. Assessing external partners can be challenging, so ASCs might develop a checklist tool to assist in making these assessments. Ensure the checklist includes items pertaining to why the ASC wants to partner with the provider. The list also can include a line for customer feedback, whether the provider fits with the health plan, whether the provider is in or out of network for patients, and whether the provider is friendly or helpful.

Document results and assess outcomes. All the preparation prior to beginning the certification process should be documented and made available to the surveyor at the time of survey. “They should provide evidence through a list of partners and demonstrate the evaluation form they’ve completed,” Poland says.

Manage continuum of care. The last part of preparing for certification is to ensure the continuum of care is managed. “One aspect of managing the continuum of care is ... how an organization is engaging with the community with education and other support,” Poland says. “One item under community engagement is that the surgery center has a written plan for community engagement and that the organization is sponsoring events, including going to a local community center and doing a healthy bone and joint session.”

Health promotion activities also can include attending health fairs, offering free educational seminars to local organizations, and providing health screenings. “AAAHC doesn’t have one big community standard because they’re such valued principles that it’s embedded through different standards,” Poland adds.


  1. The Joint Commission. Advanced Certification for Total Hip and Total Knee Replacement. Available at: http://bit.ly/30WcL2o. Accessed July 25, 2019.
  2. Accreditation Association for Ambulatory Health Care. Certification. Available at: http://bit.ly/2SEVOXe. Accessed July 25, 2019.