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The Joint Commission (TJC)

If you are preparing for a Joint Commission Survey, TJC Environment of Care standards require organizations to develop plans in 6 high functional areas of a surgery center; Safety, Security, Hazards Materials and Waste, Fire Safety, Medical Equipment, and Utilities. Strict attention is delegated to the Life & Safety Code inspection portion of the facility which I have mastered. You can achieve accreditation or Medicare deem status to participate in the Medicare program. The Joint Commission accredits and certifies more than 17,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organizations commitment to meeting certain performance standards.

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

If you are preparing for an AAAASF Survey, AAAASF basic mandates are strict and I have noticed that this organization follows its mandates as they are written. Some inspectors from other organizations stray from the written standard but not AAAASF. You can achieve accreditation or Medicare deem status to participate in the Medicare program. Today 1000’s of ambulatory surgery facilities are accredited by AAAASF, the largest not-for-profit accrediting organization in the United States. Many more facilities are in process for accreditation. These numbers have increased dramatically over the last two years. Surgeons, legislators, state and national health agencies and patients acknowledge that AAAASF stands alone as the program setting the "Gold Standard" for quality patient care.

Accreditation Association for Ambulatory Healthcare (AAAHC)

If you are preparing for an AAAHC Survey, I find that the application and scheduling process is the easiest and fastest. The turn-around time to get questions answered in writing via email is prompt. You can achieve accreditation or Medicare deem status to participate in the Medicare program. The Accreditation Association currently accredits over 4,600 organizations in a wide variety of ambulatory health care settings, including ambulatory and surgery centers, managed care organizations, as well as Indian and student health centers, among others.

Institute for Medical Quality (IMQ)

Effective November 8, 2019, IMQ is not accepting accreditation applications nor accepting accreditation renewals. However, we intend to continue to provide necessary services to those facilities who have already been accredited by IMQ. For such facilities, we are working to develop a transition plan, with the relevant regulators as necessary, that would give the facilities time to transition their accreditation to an alternative accrediting body when appropriate and desirable. We are also working on addressing similar issues for the facilities that recently applied for accreditation or that are waiting to be surveyed.  Please do not hesitate to contact us if you think your facility is in such a situation.

IMQ has worked with The Joint Commission to facilitate an expedited process for facilities and practices looking to transition to The Joint Commission.

For more information, contact:
(415) 882-5151

Healthcare Facilities Accreditation Program (HFAP)

Under the requirements of HFAP: An ASC must be certified and approved to enter into a written agreement with CMS. Participation as an ASC is limited to any distinct entity that operates exclusively for purposes of providing surgical services to patients not requiring hospitalization (i.e., an inpatient stay in a hospital). HFAP has deeming authority to accredit ASCs. This program's requirements incorporate the CMS Conditions for Coverage (CfC) along with other patient safety and quality related standards.

Centers for Medicare and Medicaid Services (CMS)

Section 1865(a)(1) of the Social Security Act (the Act) permits providers and suppliers "accredited" by an approved national accreditation organization (AO) to be exempt from routine surveys by State survey agencies to determine compliance with Medicare conditions.  Accreditation by an AO is voluntary and is not required for Medicare certification or participation in the Medicare Program.  A provider’s or supplier’s ability to bill Medicare for covered services is not impacted if it chooses to discontinue accreditation from a CMS-approved AO or change AOs.  Section 1865(a)(1) of the Act provides that if the Secretary finds that accreditation of a provider entity by a national accreditation body demonstrates that all applicable conditions are met or exceeded, the Secretary may deem those requirements to be met by the provider or supplier.  Before permitting deemed status for an AO's accredited provider entities, the AO must submit an application for CMS review and approval.