The COVID-19 vaccine rollout poses unique challenges for surgery centers and their accreditation organizations. For one thing, it is difficult for an accreditation organization to quickly develop related standards or make changes.

“We need to acknowledge how fluid the situation is,” says Frank Chapman, MBA, chair of the standards development committee at the Accreditation Association for Ambulatory Health Care (AAAHC). “The accreditation process of developing standards takes a certain amount of time. Most of the accrediting bodies have yet to establish specific standards related to COVID-19 and best practices.”

This leaves surgery centers with the task of interpreting existing standards in a way that encompasses what is required for COVID-19 and how to handle the vaccine and its administration. The best course of action is for leaders to refer to accreditation standards on vaccines for general guidance. They can follow the specific recommendations made by the CDC.

“Then, they can develop their own policies and procedures and how they’ll handle that within their organization,” says Chapman, director of strategic development for the Ohio Gastroenterology Group in Columbus.

Policies should include documented training of all employees who would handle or administer the vaccine. Include details on vaccine storage and controls, too. “Staff in a survey would need to demonstrate knowledge of the procedure on how to handle storage and delivery of the vaccine,” Chapman says.

AAAHC’s vaccine guideline (11.P) is about vaccines in general and not necessarily specific to the COVID-19 vaccine. This guideline includes these checkboxes:

  • Nationally recognized guidelines for vaccine storage and handling are followed.
  • Nationally recognized guidelines have been adopted by the governing body.
  • Written policies and procedures are present for routine storage and handling.
  • Written policies and procedures are present for storage, handling, and transport in case of emergency (e.g., equipment failure, power outage, natural disasters).
  • Documentation demonstrates that staff who receive, handle, and/or administer vaccines have been trained on the policies and procedures.
  • The vaccine storage unit is equipped with a temperature monitoring device in accordance with the adopted guidelines.
  • Staff demonstrate knowledge of procedures to follow if vaccines are exposed to a temperature excursion.

One of the challenges is finding up-to-date resources on COVID-19 because so many of the resources, including CDC courses, lack specifics about the COVID-19 vaccine in an ambulatory setting.

The CDC’s Vaccine Storage and Handling Toolkit, published in November 2020, includes the most detailed information. While these do not address the vaccine distribution challenges faced by ambulatory sites, it does provide storage, handling, and staff education information.1

“One thing that is interesting [in the CDC toolkit] is that on page four, there is something called a ‘cold chain flowchart,’” Chapman observes. “It actually is kind of a description of the chain of custody of a vaccine related to monitoring temperature.”

This information is especially important for the Pfizer vaccine, which requires ultra-low temperature maintenance. “Because of that, it is unlikely ambulatory surgery centers [ASCs] would be able to administer that particular vaccine due to the temperature requirements,” Chapman offers. “It could be possible for ASCs to provide ... the other vaccines that are possibly downstream.”

AAAHC does not require accredited organizations to create vaccine mandates. “Many hospitals actually require 100% of clinical staff to be vaccinated,” Chapman notes. “However, we encourage the identification of staff who have refused the vaccine, and there should be some mitigation in terms of what you do if someone refuses the vaccine.”

With flu vaccines, organizations might move staff who refuse the shot to work in non-contact roles, or they might be required to wear a mask. Regardless, surgery centers likely will continue to direct all staff to wear personal protective equipment (PPE), including masks, through most of 2021, or until the pandemic ends.

“We have to get to the point where enough people have been vaccinated that the transmission rate and diagnosis rate are low,” Chapman explains.

Accredited organizations should not become lax in their PPE requirements during the long period in which the United States is vaccinating the public while still battling COVID-19 infections, hospitalizations, and outbreaks. “I hope people are not being reckless now, mistakenly assuming that in a month or two everything will be good,” Chapman says. “It will take many months to have people vaccinated and to lower the risk of clinical individuals providing care.”

AAAHC has been developing a COVID-19 readiness checklist that covers most of the tasks organizations need to handle during the pandemic.2 “It was developed for organizations that were closed due to state regulations and then reopened,” Chapman says. “It’s the type of thing AAAHC is doing to stay current with COVID-19 challenges.”


  1. Centers for Disease Control and Prevention. Vaccine Storage and Handling Toolkit.
  2. Accreditation Association for Ambulatory Health Care. AAAHC surveys prioritized or postponed and COVID-19 resources.