Policies & Procedures Manual

The ambulatory surgery center or office based surgery center must adopt, employ, and regulate policies and procedures of the center.  This process will be in the form of what is called the Policy and Procedure Manual.  The surgery center policy and procedure manual must have a written policy that dictates the procedure for all aspects of the center.    This manual will be considered the nucleus of the center.  The surgery center policy and procedure manual will describe characteristics and functions of the center and compliance to situations to the attainment of quality patient care.

Surgery center policies and procedures are never-ending.  When you purchase your accreditation organization of choice standards manual, in it you will be provided with the core standard chapters in which you have to meet.  While viewing the core standard chapters you get an idea of what policies your surgery center will need to adopt.  Unfortunately I wish at the back of the standards manual they provide you with a list of each and every policy you need to have, but they don’t.   The good news is when you are reading the core standard chapters or the Medicare Interpretative Guidelines; you can get a good feel for the policies you need to adopt.  Also refer to the index portion of the accreditation standards manual; I look at the index as a baseline for what I need.  In some circumstances the standards manual and Medicare Interpretative Guidelines do mention some policies you need to have.  Remember when they mention a policy make sure you have policies that cover all aspects of the subject.  This way it will equip you with information you need to have written on hand and available to show.  In some cases a surveyor will ask for a policy and if you do not have the written version instead just answer what the situation or procedure will entail and then create the policy to show.

Get your digital ASC policies and procedures manuals from our order page.

If you currently have a surgery center then you know the basics of what policies the surveyor will ask for.  These basic staple policies are the following:


Advance Directive

Time Out

Quality Management and Improvement

Medical Staff Appointment

Adverse Incident

Peer Review

Infection Control

Discharge Guidelines

Disaster Preparedness, Fire Safety & Evacuation


Discrimination and Harassment

The above referenced polices are common and can be found in just about any policy and procedure manual you purchase.  I highly recommend if you are going to purchase a policy and procedure manual for your surgery center or for your ancillary healthcare center that you do purchase it from an entity that knows the standards therefore the manual can be customized to benefit your center.

The surgery center policy and procedure manual has to be presented, approved, and documented by the Governing Body of the center.  The Governing Body assumes full legal responsibility for determining, implementing, and monitoring policies governing the surgery center’s total operation.

Mentioned in earlier posts documentation is everything and you will have to document when your surgery center policy and procedure manual was reviewed and revised.  What new policies have you added?  Some of the new policies I have been asked for at recent surveys include:

Fall Prevention

Dismissal of Patient from care


Safe practices for Syringes and Injectables

Autoclave Monitoring

Emergency Drugs


Communicable Diseases

Each year the accreditation organizations revise the standards manual therefore you will need to revise your policy and procedure manual at minimum on an annual basis.

Here’s to your success,



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