Need help with Re-accreditation and certification?

Now that you are up and running –Congratulations, you fall into the category whereby you have been awarded surgery center accreditation and/or certification for a term.  That term is either the following:

6 months

1 year

3 year (s)

When that term is nearing the end you will have a re-survey.  If you are certified you do not have to repeat the enrollment process to Medicare.  You only notify Medicare if there have been changes to ownership or operational components for example if you had a change of ownership or a change in a billing company.

You do however have to re-apply to the accrediting body or deemed status provider to initiate the process.  Don’t worry these organizations will remind you up to 6 months prior to your expiration date.  Keep in mind that now you have a history and during the re-accreditation/certification the surveyors will be looking for data and indicators to track the history and assess your monitoring processes.

Let’s play the “WHEN” game!

When was the last time you had a Governing Board Meeting?

When was the last time you reviewed your vendor contracts?

When was the last time you had a quality meeting?

When was the last time you did a quality improvement study?

When was the last time you performed benchmarking?

When was your last In-service?

When the last time peer reviews were performed?

When was the last time your equipment was calibrated?

If you can’t answer these questions immediately you are not ready.  You can start by focusing on these questions to prepare a punch list of what you have to do to get ready.  The bad news is that the above referenced items are just a small portion of the standards that you have to meet.  Remember in this business documentation is key.  You have to show documented proof that you are adhering to these standards.

When I am helping facilities with the Re-accreditation and certification process the above items are never kept up.  Most should be done on a quarterly basis, some annual or semi-annual depending on your policy.

Here is a question to ponder!

How long has your medical staff been performing procedures at the facility?

Standard policy is to grant medical staff membership for 2 or 3 years.  (What’s in your policy?) If the medical staff member has been on staff longer, have you taken them through the RE-appointment process?

For more information I am available for consultation and for service if you need assistance on the surgery center re-accreditation/certification process.  You can reach me at ABA headquarters.  Contact information can be found in the “about me” tab or email me at

Here’s to your success


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