Quality and Risk Management in Ambulatory Surgery Facilities


Regulatory compliance is a complex process that requires constant attention, targeted education and focused oversight.

The healthcare industry is highly regulated and all organizations must adhere to specific requirements to ensure they are providing high quality patient care. Ambulatory surgery centers (ASCs) are subject to their own set of regulations, depending on the regulatory and accrediting agencies, which is different than the hospital requirements.

ASCs who seek to participate in the CMS program are subject to meeting a set of rules called “Conditions for Coverage,” which are different than the “Conditions of Participation” that the hospitals are subject to across the country.

Regulatory compliance is a complex, continual process for those providing and overseeing clinical care and the responsibility for oversight of a regulatory program can be downright intimidating. ASC leaders are forced to navigate the world of regulatory compliance while multitasking and functioning in several roles at their facilities. It is clear that ASC Administrators and OR leaders are being asked to work in a post-pandemic world full of staffing, supply chain and operational challenges - and adding regulatory compliance can become overwhelming.

In response to feedback from our ASC leaders, we have created a new series of education products that bundles modules included in the ASC Academy: Leadership Development course. The series will include all the modules from the ASC Leadership Development Academy broken into smaller bundles and with the newly developed implementation guide including customizable tools specific to the topics covered. The series will be called “ASC Academy: A Guide to…” with the first in the series called “A Guide to Quality and Risk Management.”

As I sat down to create “A Guide to Quality and Risk Management,” I began to feel the same anxiety as when I was tasked with creating a quality program for an ASC. At the time, my experience was all inpatient and the hospital had entire departments dedicated to quality and risk management. How was I expected to learn the ASC specific requirements, meet the collection and reporting requirements and avoid the 2% penalty from CMS for failure to report?

The conceptualization of this course was an intentional process of collaboration with my colleague Jonny Marr to review the feedback, prioritize the needs and create a series of tools to solve a problem. It was easy to empathize with our colleagues and create the tools that would set ASC leaders up for success.

The course was developed by performing research of the CMS and accrediting agencies requirements, specifically calling out documentation requirements and the most cited deficiencies. The intent was to create tools that allow the Administrator to input their own data into the compliance tracking tool, assign tasks, collect data, monitor and report findings. With this tool, the Administrator will be able to create, revise, review, update and report on their quality program to meet the regulatory requirements of their specific agency.

We are excited to launch these new education products that break down the requirements into manageable courses that include the foundational information and the implementation guide with step-by-step instructions and tools for success.

For more information on the new education course, go to ASC Academy: A Guide to Quality and Risk Management | AORN. OSM

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