Surgery center inspections compared to taco trucks and come up short

Washington Postarticle points to lack of federal funds for state reviews

Taco trucks are inspected twice a year in California, while ambulatory surgery centers (ASCs) are inspected an average of once every 12 years in that state. That eye-catching news introduced a Washington Post story published in July that went on to say that under federal rules, surgical centers across the country are required to be inspected once every six years, but many are not.1

"This has been an ongoing problem within the state [of California] and will continue to be a problem as long as the DHS [Department of Health Services] remains understaffed and underfunded," says Arthur E. Casey, CASC, president of the Sacramento-based California Ambulatory Surgery Association (CASA). California does not have a specific regulation related to frequency of surveys as some other states do, Casey explains. "Arizona, for example, requires surveys to be conducted annually for a facility to maintain its licensure," he says.

DHS in California can’t provide that level of review annually without doubling the size of the department, Casey adds. "Even if the legislature were to enact a requirement for surveys, unless specific funding is also authorized, the department would be unable to comply," he says.

States rely on the Centers for Medicare & Medicaid Services (CMS) for most of the money they use to inspect surgery centers and other health care facilities. Regulators from several states say federal funding is lacking and has restrictions, so they must prioritize their inspections, according to the story.

Under congressional rules, nursing homes must be inspected annually, and that requirement takes about 70% of their oversight funds, the story said. "The result is that thousands of facilities, including outpatient surgery and kidney dialysis centers, go years without review," the Post said.1 The article did not refer to any patient health and safety problems associated with the care provided in ASCs.

Thomas E. Hamilton, director of the Survey & Certification Group, wrote in the article that Medicare officials have put inspections into four levels of priority, with nursing homes in the top priority tier and surgery centers in the bottom one.1 When states run out of funds, they cut back on the bottom tier first, he noted.

The federal budget requires prioritizing where the greatest need for quality oversight is, says Craig Jeffries, Esq., executive director of the American Association of Ambulatory Surgery Centers (AAASC) in Johnson City, TN. "While ASCs are not an area of high priority because of their good experience, AAASC does not want the absence of periodic inspections to raise concerns about patients receiving optimal care," he says.

"In our experience, accreditation provides an important alternative where the public can be assured that health care facilities, including ambulatory surgery centers, meet rigorous and contemporary standards for patient health and safety," Jeffries adds.

Are surgery centers safe?

Casey says he is not greatly concerned by the lack of state surveys in California for several reasons. One is that, in general, there typically are fewer problems identified in ASCs than in skilled nursing facilities (SNFs) or general acute care hospitals, he notes. Additionally, the vast majority of ASCs in California are accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) or the Joint Commission on Accreditation of Healthcare Organizations. Several surgery centers have deemed status and are surveyed randomly at least every two to three years, Casey says.

"Also of note is that the accreditation process is voluntary, so the ASCs are subjecting themselves to this review on their own accord," he points out.

The California DHS has pushed to survey the vast majority of ASCs throughout the state in the past couple of years, Casey says.

"In fact, every facility that I have worked with has been surveyed in the last three years," he continues. DHS also investigates all complaints made against any facility, Casey explains, "so although there may not be a consistent frequent schedule for surveys, those facilities that have had complaints filed are surveyed."

The national Office of Inspector General (OIG) performed a study a few years ago on quality oversight in surgery centers, and the OIG did identify for CMS that some states had quite a period of time lapsing between inspections, says Kathy Bryant, executive vice president of the Federated Ambulatory Surgery Association in Alexandria, VA.

"Their recommendation is exactly what CMS did: CMS should consider the nature and risks of ASCs in determining when they should be surveyed," says Bryant, who points to Hamilton’s explanation of a four-tired system that cuts out inspection from the bottom tier.

"I think that, like myself, CMS is saying it’s not greatly concerned about ASCs, that they seem to be operating very safety," she notes.

Both patient care and surgery centers are incredibly safe today, Bryant says. "We certainly have no problem with ASCs being inspected more frequently — as long as government officials allocate funds to do that regular surveillance," she says. "I don’t think that because surgery centers aren’t inspected more frequently, that patients are at risk when they go to surgery centers."

The California association fully supports consistent unannounced surveys of all health care facilities, Casey says.

"Unfortunately, being compliant with regulations does not necessarily correlate to high-quality patient care," he explains.

"It only means that the facility is good at completing paperwork; but for now, this may be the best method possible," Casey adds.


  1. Gaul GM. Lack of funds reduces frequency of health inspections. Washington Post, July 25, 2005:A08. Web site: