SDS Accreditation Update

Check LSC compliance with new publication

Document focuses on ambulatory settings

Same-day surgery programs preparing for a Medicare survey can find help in complying with the Centers for Medicare & Medicaid Services’ (CMS’) 2000 Life Safety Code in a document focused on same-day settings from the Accreditation Association for Ambulatory Health Care (AAAHC).

The AAAHC physical environment checklist was developed to help same-day surgery programs that are scheduled to go through a Medicare deemed-status survey through AAAHC, says Joan Riebock, senior director of program operations.

The checklist, however, can be helpful to any ambulatory health care organization that must meet CMS’ code requirements (For more information on the code, see "Medicare adopts 2000 Life Safety Code," Same-Day Surgery, March 2003, p. 32.)

"AAAHC developed the checklist because the code is a very comprehensive document that covers a variety of organizations," she explains. "This document helps same-day surgery managers focus on the issues that apply to their setting."

The most controversial aspect of the 2000 Life Safety Code is related to organizations that may assume they will be grandfathered, Riebock says. If the same-day surgery program is in compliance with earlier editions of the code, there is no need to upgrade, unless the facility undergoes renovation or any type of remodeling, she adds. "The controversy lies in the definition of renovation and how extensive the remodeling must be before the facility is required to upgrade all systems to the 2000 requirements," she explains.

The checklist addresses issues such as:

  • general requirements;
  • exiting requirements;
  • electrical requirements;
  • medical gas and vacuum systems;
  • fire protection;
  • building services;
  • operational issues.

Although there are no specific educational requirements for the person who oversees the program’s compliance with the code, Riebock recommends that the person have more than only administrative or only clinical experience. "I suggest that the person who is reviewing the checklist for compliance be knowledgeable about the areas covered by the 2000 Life Safety Code," she adds. For example, a hospital-based program often uses the hospital engineer to review compliance, she explains.

Freestanding centers that do not have on-site engineers or other employees with a thorough knowledge of the physical structure aspect of the same-day surgery program, might want to consider a consultant, she suggests. "We’ve found that many requests for our publication come from architects or general contractors who are building new same-day surgery centers and want to make sure they are in compliance," she says.

AAAHC organizations completing the code self-assessment prior to their survey should be as accurate as possible, Riebock suggests.

"It behooves the organization to be as thorough in the initial review as possible and identify any areas of noncompliance along with the corrective action," she says. "If there are discrepancies when the surveyor arrives, the organization will not get a favorable survey."

Sources and Resources

For more information about deemed status surveys and the 2000 Life Safety Code, contact:

  • Joan Riebock, Senior Director of Program Operations, Accreditation Association of Ambulatory Health Care, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091-2992. Telephone: (847) 853-6060. Fax: (847) 853-9028. E-mail:
  • The Accreditation Association for Ambulatory Health Care Physical Environment Checklist can be ordered at the web site The cost is $100. The publication is based upon the 2000 Life Safety Code requirements that apply to ambulatory settings. The book is available on CD-ROM only.
  • The Joint Commission on the Accreditation of Healthcare has a Statement of Conditions guide to compliance with the Life Safety Code for all health care organizations. Go to, choose "accredited organizations," choose "ambulatory care," then click on "standards" on left tool bar and then choose "statement of conditions."