SDS Accreditation Update: Accreditation can help meet regulatory requirements

Joint Commission and AAAHC monitor activity and keep you updated

State licensure regulations, Medicare regulations, Health Insurance Portability and Accountability Act (HIPAA) requirements, and accreditation survey preparation can make some same-day surgery managers feel as if most of their job is compliance oversight. Even more confusing than the myriad of regulations is the need to identify the proper action to take when some compliance requirements conflict with or differ from others.

The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, and the Accreditation Association for Ambulatory Health Care (AAAHC) in Wilmette, IL, offer support to their accredited organizations to reduce some of the time required to comply with and identify compliance issues.

"We subscribe to a variety of bill- and regulation-tracking services that enable us to monitor the introduction of legislation in all states that might impact our accredited organizations," says Mark Crafton, MPA, executive director of state and external affairs for the Joint Commission. "We watch for opportunities for the Joint Commission to act as a point of oversight for health care organizations so that our accreditation can be used to meet compliance requirements."

For example, several states do recognize Joint Commission accreditation as meeting state licensure requirements, Crafton says. "This recognition gets rid of the duplication of effort for the same-day surgery program to undergo a licensure process as well as an accreditation process," he explains.

Even if your state recognizes Joint Commission accreditation, be sure you know what that recognition entails, advises Crafton. "The most common agreement is that the Joint Commission accreditation is accepted in lieu of a licensure survey," he says. While organizations in these states can choose to undergo a licensure survey rather than undergo an accreditation process, there are some states that require accreditation for licensure, Crafton says. Those states are Delaware, Georgia, New Jersey, New York, North Carolina, Pennsylvania (minor procedures only), and Virginia, he says.

There is also at least one state, which he declined to specify, that doesn’t mandate accreditation, but it determines the need for a state survey based on the result of an accreditation survey, Crafton points out.

Office surgery a hot topic

The most active area for new regulations has been related to office-based surgery, says Adrian Hoschstadt, JD, director of public affairs for AAAHC.

"Four years ago, there were only a handful of states that had any regulations related to office-based surgery, and today we have almost half of the states with something on the books," Hoschstadt says.

The requirements vary, with some states having regulations that must be followed, and other states offering voluntary guidelines, he points out.

Because the rules change frequently, AAAHC maintains a database of state regulations that apply to ambulatory care organizations. (See resource information, below.) "We find out about changes or potential changes from monitoring services to which we subscribe and also from our own accredited organizations," says Hoschstadt. "The web site provides updated information on current legislative actions as well as an overview of regulations that affect our accredited organizations."

AAAHC also maintains a current file of office-based regulation summaries that can be obtained from his office, he adds. (See Hoschstadt’s contact information in Sources and Resources, below)

Be aware, too, that some states that accept accreditation surveys in lieu of state surveys also require additional information, says Crafton. "Texas has additional anesthesia requirements, Florida has a specific list of medications that must be available, and several states require a specific written transfer agreement in addition to the transfer plan required by Joint Commission," he points out.

If a state has additional requirements, surveyors will come prepared with an addendum documenting that the organization meets Joint Commission requirements as well as the extra state requirements, he adds.

The challenge for some same-day surgery managers is figuring out which rules apply, says Hoschstadt. "You may think your organization is an office-based practice, but your state may define you as a freestanding surgery center," he explains.

The key is not to assume anything, and look at the specific language in your state regulations, Hoschstadt says. "Read the definitions carefully, and ask for explanations of language that isn’t clear," he says. Develop a good relationship with an appropriate contact on the state medical board, department of public health, or whichever agency oversees your organization, to ensure you have a good source of information, he suggests.

State associations and accreditation organizations also can provide information, but be sure that you understand the rules and requirements and that you know how your same-day surgery program is meeting those requirements, Hoschstadt says.

"Even if you use an attorney or other consultant to provide guidance for your compliance program, be aware that the ultimate responsibility for compliance is upon you," he says.

Sources and Resources

For more information on state regulations and accreditation, contact:

  • Mark Crafton, MPA, Executive Director of State and External Relations, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Fax: (630) 792-5005. E-mail:
  • Adrian Hoschstadt, Director of Public Affairs, Accreditation Association for Ambulatory Health Care, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091-2992. Telephone: (847) 853-6072. Fax: (847) 853-9028. E-mail:

The Accreditation Association for Ambulatory Health Care web site provides regulatory updates and summaries of state legislation related to ambulatory surgery. Go to, choose "AAAHC news," then choose "regulatory/legislative information." Click on "regulatory update" and "state laws and regulations."

The American Association of Ambulatory Surgery Centers in Johnson City, TN, offers legislative information about specific states at