Are you documenting that the center is enforcing the policies and procedures? We are underway in the 1st quarter of 2013 so make sure during your Governing Body meeting that the board review and approve the surgery center policy and procedure manual for the current year. Document this in the meeting minutes and make reference to purchasing your accrediting organization’s hand book for the current year 2013 so all staff can be up to speed with new policies and any revisions made to past policies. Call your accrediting organization or go online to see if the current year manual is available for purchase and come back here for updates. Currently I am preparing surgery centers for state licensure, surgery center accreditation with AAAASF and Medicare deems status for Joint Commission and AAAHC. I am in the process of revising polices for the Emergency Management Plan, Utilities System Management Plan and the Infection Control Program. For additional information on surgery center policies and procedures check this out.
Here’s to your success,