Each surgery center is unique however the standards to meet are the same. You must have specific surgery center policies and procedures in place. You will need to have in written format policies and procedures that reflect the following chapters:
Governance
Medical Staff

Administration
Anesthesia Services
Perioperative Care
Medications Management
Quality Improvement
Infection Control
Environment of Care
Emergency Management
Exposure Control
Central Supply and Sterilization

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. The Governing Body appoints a Medical Director to oversee the day to day clinical and administrative operations of the surgery center. If you are under going a Medicare certification inspection under the medical directorship a nurse manager must be present within the surgery center organizational structure. There must be present an organizational chart within the surgery center. When you purchase the Governance chapter of the surgery center policy and procedure manual you will have the format of the organizational chart and committee relations as well as the functions of the Governing Body.

If you are preparing for a AAAHC inspection it is mandatory to have a surgery center policy and procedure for an adverse incident. Within the policy you will need to have a definition of an adverse incident. When you purchase the Emergency Management chapter of the surgery center policy and procedure manual there is a complete policy covering an adverse incident including the definition of an adverse incident.

If you are preparing for a Joint Commission inspection it is mandatory for you to have a surgery center policy and procedure for the history & physical. This is also a Medicare certification requirement. When you purchase the Perioperative Care chapter of the surgery center policy and procedure manual there is a complete policy covering the history and physical which cross reference to the CMS requirement.

If you are preparing for a AAAASF inspection you must have a policy for it is mandatory that you have a surgery center policy and procedure for the frequency of the biological indicator. When you purchase the Central Supply and Sterilization chapter of the surgery center policy and procedure manual there is a complete policy covering the frequency of the biological indicator.

Pass your inspection by downloading the chapters of Accredia® surgery center policy and procedure manuals.