Some of the most common deficiency findings by accreditation organizations include problems in the areas of infection control, documentation, safe injection practices, and medication disposal and storage issues.

Recently, life safety standards have become one of the top problem areas.

Targeted quality improvement practices could help resolve problems with safe injection practices.

Credentialing is another problematic area, as surgery centers often overlook checking annual items that can expire, such as medical licenses.

Infection prevention and documentation were among the top reasons why surgery centers, in various ambulatory settings, were found deficient in accreditation surveys, according to the 2019 AAAHC Quality Roadmap report.1

“The areas with high deficiencies tend to be those that are relatively complex, such as safe injection practices, including storage and handling of single-dose vs. multi-dose medications, immediate use, labeling, and medication disposal,” says Naomi Kuznets, PhD, vice president and senior director, Accreditation Association for Ambulatory Health Care (AAAHC) Institute for Quality Improvement.

Some high-deficiency standards appear year to year in AAAHC’s annual quality roadmap report, but surgery centers are improving in a few areas. “We are seeing lower overall deficiency rates with certain standards, such as conducting quality improvement studies and scenario-based drills,” Kuznets reports.

Infection prevention and life safety code standards are among the most common noncompliant standards for accredited ambulatory health organizations and office-based surgery practices, according to The Joint Commission.2 Surgery center administrators might not be familiar with the latest requirements and updates to the life safety standards related to building and fire protection systems, says Pearl S. Darling, MBA, executive director, ambulatory care services, The Joint Commission.

Until 2018, life safety code standards were not one of the top four challenging standards, Darling notes. Deficiencies related to safe injection practices could be resolved through targeted quality improvement practices, Kuznets offers.

“Some of the organizations’ staff are either unfamiliar with how to conduct quality improvement activities, or they lack an understanding of why the AAAHC requires certain components, such as specifying measurable goals, which provide clear information about whether the goal is achieved,” Kuznets explains.

AAAHC standards require attention to details, such as credentialing and privileging. This includes the use of peer review information. “Another factor relates to issues with the provider and/or staff familiarity and experience,” Kuznets continues. “Some employees have only completed desktop emergency drills vs. scenario-based ones, as required. Technology and experience also can be associated with standards’ deficiencies.”

For instance, electronic health records that do not require documentation of allergies beyond listing them fail to meet the AAAHC’s standards, which require descriptions of allergy reactions and severity, Kuznets adds.

Kuznets and Darling describe some of the other common deficiency findings and how to prevent these problems:

Infection control and prevention programs. Surgery centers should create an infection control and prevention program that reduces the risk of infections through staff education and active surveillance.

This should be a frequent area for quality improvement projects, yet it is one of the most common deficiency areas in surveys by both AAAHC and The Joint Commission.

AAAHC’s 2019 report revealed that more than 30% of Medicare Deemed Status (MDS) ambulatory surgery centers failed to meet standards with their infection prevention programs. For office-based surgery sites, more than 15% had that deficit. For both, this was the most common finding. For non-MDS sites, this also was on the list of top deficits.1

The Joint Commission’s infection prevention and control standard often is a problem for sites because there is a lack of training and education for staff responsible for maintaining these equipment, devices, and supplies, Darling says. Also, surgery centers sometimes fail to follow the manufacturer’s instructions for use. A best practice solution is to ensure the organization owns the manufacturer’s instructions for use on all supplies, equipment, and devices, Darling suggests. “Conduct process checks on your sterilization procedures and ensure staff is educated on processes approved by leaders and evidence-based guidelines or best practices," she adds.

Credentialing and privileging are incomplete. Surgery center organizations grant privileges for healthcare professionals to practice for a specified period. These individuals must be legally and professionally qualified for the privilege.

While Joint Commission surveyors have found that surgery centers have improved in credentialing and privileging, AAAHC surveyors often come across surgery centers where the credentialing process is inadequate.

“One area that often gets overlooked is checking annual items that can expire, such as medical licenses: DEA, BCLS, ACLS, and any others that are required by an organization,” Kuznets says. “Another issue is when privileges are requested that are outside the scope of the ambulatory surgery center. The requested privileges should be included on the list that has been approved by the governing body.”

Surgery centers should include allied healthcare providers and supervisor activities in their credentialing and privileging, Kuznets says. “They must ensure that credentialing and privileging information is up to date,” she says. “Peer review information should be used for credentialing and privileging.”

This includes directing each center and provider to align their scopes of practice and documenting the governing board’s work on privileging. Part of the credentialing process is clinical-based peer review, another component that is missing frequently, Kuznets observes.

“Peer review should be determined by the providers, including how often and what is to be reviewed,” she explains. “It should be based on clinical practice guidelines that are relevant to patient care.”

Other items that should be included in peer review are adverse events and transfers, along with provider behavior (if needed), Kuznets adds.

The exact wording of specific findings in the AAAHC 2019 report include (but are not limited to): “Credentialing files did not contain written requests or approvals for specific procedures,” “Peer review was not conducted for allied health or contracted providers,” and “Privileges granted for procedures were outside the scope of the center’s procedures.”1

“Routine peer review should occur on a predetermined schedule and should be completed by like peers,” Kuznets recommends. “Adverse events and transfers should also be reviewed as determined by the organization’s risk management team, and results of the peer review should be included in the provider’s recredentialing.”

Safe anesthesia services. In MDS ambulatory surgery centers, the third leading deficiency involves creating a safe environment for anesthesia services. More than one out of four sites were deficient in this area.1 “Safe injection practices include more than ‘one needle, one syringe, one time,’” Kuznets explains.

Safe injection practices also must include details about where to store medication as well as proper labeling and disposal. Other needed information should include how to draw certain medications and how to use medication within specified time frames.

This standard relates to providing adequate space, supplies, and equipment. There must be written policies for safe use of injectables as well as single-use syringes and needles. A log should be kept for preventive maintenance, and all equipment should be maintained and tested according to manufacturer’s instructions.

“Part of this problem involves how providers deliver medication,” Kuznets notes. Mistakes can include using single-dose vials as multiple-dose vials, not labeling syringes for use, improper storage of medication on anesthesia carts, and pre-spiking IV bags, she adds.

Other specific deficiencies noted in the 2019 AAAHC report include (but are not limited to): “Not treating a multidose medication opened and drawn in a patient treatment area as a single-dose vial,” “IV hub not sterilized each time anesthesia administered,” and “Single-use eye drops used on multiple patients.”1 

“Although knowledge of safe injection practices is slowly increasing, more progress needs to be made,” Kuznets says.

Medication reconciliation, allergies. The AAAHC report noted deficiencies related to medication use and reconciliation. For example, a surgery center might not include documentation about which medications they instructed a patient to discontinue prior to a procedure and when, how, or whether the patient should resume the medication.

“Similarly, a new medication may be prescribed for the patient, but documentation on when and how the patient is supposed to use it might be missing,” Kuznets says.

Patients need to take a document to the next provider that explains medication reconciliation, discharge medications, and continuation of current medications, she adds. Even surgery centers that do not use electronic health records should be compliant with this standard. “A less complete electronic health record does not excuse incomplete medication reconciliation,” Kuznets cautions. Another issue is related to allergies. Some surgery centers fail to consistently document allergy severity and patients’ reactions.

“For example, a localized rash is quite different from anaphylaxis,” Kuznets observes. “We currently have a toolkit on allergy documentation, and, beginning in 2020, the AAAHC will be offering a benchmarking study on allergy documentation.”


  1. Accreditation Association for Ambulatory Health Care. 2019 AAAHC Quality Roadmap: A report on accreditation survey results. Available at: http://bit.ly/32LzjEi. Accessed Oct. 24, 2019.
  2. Webb J. Top 10 most challenging ambulatory care and office-based surgery standards for 2018. The Joint Commission, April 17, 2019. Available at: http://bit.ly/2qJx7zh. Accessed Oct. 24, 2019.