Ambulatory surgery centers (ASCs) will find some important updates in the latest version of the Accreditation Association for Ambulatory Health Care (AAAHC) handbook.

In September, AAAHC published the Accreditation Handbook for Medicare Deemed Status, version 41, the first time the handbook is marked by a version number and not by the year of release. Perhaps most notably is the inclusion of a standard on vaccine management.

The importance of this standard has been amplified during the COVID-19 pandemic, as the world waits for a safe and effective vaccine that could be distributed to 7.8 billion people.

“A lot of surgery centers, in the past, have had vaccines only for staff,” says Meg Kerr, MPA, vice president of standards development for AAAHC. “But now we live in a new world, with new vaccines for new uses. Although we were not aware of that when the standard was created, it has taken on new significance.”

Issuing revised standards during a pandemic was challenging, but AAAHC decided the changes could benefit accredited organizations.

“The changes being made, we believe, will help clients [develop] more clear and consistent programs,” says Hallie Brewer, CA-AM, senior vice president of learning and development for AAAHC. “It helps [clients] have a way better picture of how we are evaluating them with standards. We believe the changes we’ve made will make things more understandable and make things more clear.”

Version 41 of the accreditation handbook will be used by all sites with an accreditation anniversary date on or after Nov. 1, 2020. Ahead of the handbook’s September release, AAAHC published a primer to help clients understand the coming changes.1

“In the back section of each book, there is a crosswalk to the previous version,” Kerr says. “If they want to see what’s changed the most in the book, then that’s their snapshot of what’s changed and what is deleted.”

Brewer and Kerr outline several other notable updates:

Surgical site marking. Version 41 includes standard 10.I.O, which is 10.I.S in the Medicare deemed status program, for marking a site prior to surgery. The standard states: “Prior to a surgery or procedure involving level or laterality, the site is marked.”

It also requires five elements of compliance, including “a written site-marking policy is present” and “clinical records contain documentation of site-marking.”

“We clarified that the standard only applies if the organizations conduct certain surgeries and procedures,” Kerr says.

For example, the standard applies to procedures involving level or laterality. “Our last version of the handbook noted that the standard did not apply to endoscopic procedures,” Kerr explains. “This time, we changed it to clarify level and laterality.”

The revised standard also removed the statement indicating the site can be marked only by the person providing the procedure, aligning this standard closer to CMS regulations regarding site-marking. Now, another member of the surgical team can mark the surgical site, so long as that member is going to be in the OR during the time out. Surgery centers will need to define what they mean by “surgical team” and who is included on it. However, centers that work under a policy that only allows the person performing the procedure to mark the site can keep that policy.

AAAHC does not always align its standards to CMS rules. “We always assess what we believe is the best thing for the patient,” Brewer explains. “There are some other changes where CMS may have lightened the requirements, but we believe it should still remain as it is now because it’s better for patient safety. But, in this case, we believe the change is appropriate and common practice.”

High-alert medications. Version 41 includes standard 11.G and 11.H, which are standards 11.I and 11.J in the Medicare deemed status program, for procedures to prevent high-alert medication errors.

Surgery centers must keep a list of high-alert medications, put processes in place to prevent errors from administration of these medications, and maintain a system for keeping the drugs with sound-alike/look-alike names separate so staff know which is which. The handbook includes a link to the Institute for Safe Medication Practices evidence-based list of high-alert medications.2

High-alert medications are not necessarily more dangerous. However, administering the wrong dose can lead to major trouble.

“People thought they could download a list from a website and meet standards,” Kerr observes. “Now, we say that sites have to be aware and monitor their medication on a regular basis for the presence of those types of drugs.”

If a surgery center does not stockpile any of these problematic drugs, then they do not have to do anything more than monitor and document that those drugs are not at the center. “If you do find some of those drugs, then the standard has additional requirements to make sure you’re taking steps to prevent potential errors from the use of those medications,” Kerr adds.

Quality improvement (QI) process. Version 41 includes standard 5.I.D, which is standard 5.I.G in the Medicare deemed status program: “The organization demonstrates that continuous improvement is occurring by conducting quality improvement studies when the data collection processes, described in Standard 5.I.C, indicate that improvement is or may be warranted.”

The standard’s elements of compliance include this example: “At least one current quality improvement study demonstrates that improvement occurred and has been sustained.”

“Quality improvement is something we care a great deal about,” Brewer says. “But we also find it’s an area that organizations struggle with because it’s not always easy to come up with a great QI study.”

“For a long time, we had 10 elements of the quality improvement process,” says Kerr, noting that now, the 10 elements are no longer included; in version 41, they are detailed in the back of the handbook. “There has to be at least one completed QI study in order to be in compliance with that standard, while previously they were expected to have at least two QI studies when they applied for a survey,” she says. “But there was no time frame given on that.”

Version 41 includes a specific time frame: At least one QI study must be performed within the current accreditation term of three years, or within the last 12 months of the initial survey, Kerr explains.

Smaller sites might be expected to conduct fewer QI studies, while larger sites might be expected to perform one each year. “The number of QI studies they conduct has to reflect the nature and complexity of the facility,” Kerr says.

When leaders observe a decline in any process quality, that is the time for an improvement project. “Monitor performance indicators on an ongoing basis and take steps, as needed, to show improvement occurs,” Kerr offers. “Find an issue with the current process, find ways to improve it, implement those steps, remeasure to see if steps improve it, and, if so, you’re good to go. If not, then take further steps.”

AAAHC says it will no longer tie an edition of its handbook to a calendar year. The group has pledged to issue changes whenever it makes sense, using version numbers from now on. “We often find that an annual change is the right call,” Brewer says. “The change could be for clarity and evolved medical practice, or because of a shifting landscape and living in a post-COVID world.”


  1. Accreditation Association for Ambulatory Health Care. Standards & policy updates. Last updated Sept. 7, 2020.
  2. Institute for Safe Medication Practices. ISMP list of high-alert medications in community/ambulatory healthcare. 2011.