Welcome to Surgery Center Accreditation 101

This is a place to learn all about surgery center accreditation and certification for outpatient settings such as ambulatory surgery centers, clinics, urgent care settings, skilled nursing and the list goes on.  Whether you are up for re-accreditation/certification, it does not matter this is the blog for you.  In post to come I will provide you with tips on development and design as well. If you are thinking about starting your own center this is a good place to get some guidance so you will be led in a positive direction and you can create the center of your dreams.   If you are up for the re-accreditation/certification you will be guided in the right direction.

The owners and operators of surgery centers (you could call these individuals Members of the Governing Board…we’ll get into that later if you don’t know what that means) are familiar with the accreditation or certification process but none the less find themselves pressurized with the process.    Our goal together is to get you to meet the standards and conditions of this rigorous regulatory process.  The journey we will take together.  “101” refers to getting down to the basics and we will start from the beginning.

There are several ways to meet the standards of accreditation. Very few ways to meet the conditions of certification (Medicare).   Surveyor (s) will not tell you that verbally but how many times have you provided documents in which they asked for and then, “THINK ABOUT THIS NOW” the surveyor will suggest another way for you to do what you have already done!  What about the conditions and standards that you have not met?  I can write a book on what’s not getting done, that would be very negative and frustrating.   The easier way is to blog and consult.

Certain outpatient settings are required to be licensed by the state, obtain Medicare certification, or become accredited by an approved accrediting agency.   Check with your state medical board or DHS to find out whether you can be licensed or go through an approved agency such as AAAHC, AAAASF, The Joint Commission, and HFAP.  These “certain” outpatient settings are classified as surgery procedure settings using anesthesia (except local or peripheral nerve blocks).  If you are planning on administering anesthesia in doses that have the probability of placing a patient at risk to loss of reflexes, loss of responsiveness, total lack of awareness or all simultaneously, you need to be licensed, accredited or obtain certification.

What is the difference between Accreditation and Certification?

The accreditation process provides you with the authority to administer anesthesia and also reflects on the day to day operations including, governance, administration, policies and procedures, quality improvement, emergency equipment, fire safety, business class and profession codes pertaining to the performance of procedures using anesthesia and last but not least patient care.  There can be a drawback with accreditation in that some insurance companies will not pay out the facility fee to just accredited facilities.

Certification deals with not only the requirements you have to meet for accreditation but the center must meet the requirements of the National Fire Protection Association (NFPA) codes and standards and provisions of the business class and professions codes which meet Medicare requirements.  Think about the “physical facility” as a whole whether free standing or a part of a building with many storeys.   Medicare has extensive requirements that must be met.   So keep the following in mind for the certification requirements:

Construction, Architectural, and Engineering

Medical Gas System

Essential Electrical System

Operations (testing and maintenance)

Although the above is referenced to certification you must keep in mind a portion holds true for accreditation as well but there is leniency to accreditation.  For example for accreditation you can get by with an UPS for backup power.  Certification you need a Type I or Type 3 Essential Electrical System to include critical care panel, life safety panel, and equipment panel.  Other requirements fall under the EES (essential electrical system) such as main and feeder panel and annunciator panel.

In blogs to come we will go over the difference between a Type I and Type 3 EES.

Now let’s see if you are sharp & alert.


If you are planning on administering anesthesia in doses that have the probability of placing a patient at risk to loss of reflexes, loss of responsiveness, and total lack of awareness or all simultaneously your facility must be?


Licensed, accredited or obtain certification by an approved accrediting agency.  Check with your state medical board.

For more information I am available for consultation and for service.  You can reach me at ABA headquarters.  Contact information can be found in the “about me” tab or email me at nb@abmsc.us


Here’s to your success


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