Circulation 60,475 • Volume 15, No. 1 • Spring 2000

3 Different Organizations Can Accredit OBA Sites

Office-Based Anesthesia Accreditation Varies; Most Sites Have None At All

JCAHO (the Joint Commission for Accreditation of Healthcare Organizations), AAAHC (the Accreditation Association for Ambulatory Health Care), and AAAASF (the American Association for Accreditation of Ambulatory Surgery Facilities) are accreditation organizations which have received “deemed” status from Medicare. JCAHO standards are the same whether Medicare certification is sought or not. AAAHC standards are almost the same, but if the center is not seeking Medicare certification, there are a few standards that would not apply. With AAAASF there are many standards which are not applied if the center is not Medicare certified. In Florida, however, most of Medicare certification Conditions of Participation are in section 59-A, so if a facility is state licensed, it probably is in compliance with Medicare Conditions of Participation.

Centers requesting the Medicare review from AAAASF must meet the additional standards of Medicare Conditions of Participation and the Life Safety Code 101 for the physical plant.

JCAHO and AAAHC will not accredit a freestanding surgery center unless it is also licensed in the state, when that state has licensure of surgery centers. AAAASF does not require state licensure. This significant difference can result in physical plant specification requirements that are not as stringent as those of the other two accrediting organizations. All three organizations will accredit an office-based surgery facility. JCAHO and AAAHC have focused their efforts on the hospital based and freestanding surgical facilities. AAAASF focuses its efforts on the office-based center.

The origin of AAAASF dates back to 1980 when the American Association for Accreditation of Ambulatory Plastic Surgery Facilities, Inc. was created. In 1992, the AAAASF was established for accreditation of all American Board of Medical Specialties (ABMS) board certified surgical specialties office-based surgery units. Its program is strongly aligned with the contents of the 1994 American College of Surgeons publication, Guidelines for Optimal Office-based Surgery.

AAAASF requires that the surgeons who perform procedures in the facility be board certified or board eligible in an ABMS surgical or anesthesia specialty. Only those procedures for which acute care hospital privileges are held may be performed within an AAAASF accredited facility. It does not recognize podiatry or dental board certification as qualifications. AAAASF realizes that centers may provide different levels of services and therefore their requirements are targeted to three separate classes of service. The classes are based on the tiered classifications of anesthesia used and are defined as:

  1. All procedures performed in the facility are under local or topical anesthesia.
  2. Surgical procedures performed in the facility encompass Class A type and are performed under intravenous or parenteral sedation, regional anesthesia, analgesia or dissociative drugs without the use of endotracheal or laryngeal mask intubation or inhalation general anesthesia (including nitrous oxide).
  3. Surgical procedures performed in the facility include Class A and B types with the use of endotracheal or laryngeal mask intubation and/or inhalation anesthesia which is administered by an anesthesiologist or a Certified Registered Nurse Anesthetist.

Each of the classes of facilities has AAAASF standards to meet. Each progressive classification must meet the criteria of the previous class, and therefore the most advanced facilities must meet all of the standards or criteria listed. Again, more standards are added if the center is seeking Medicare Certification.

The AAAASF Accreditation Program requires 100% compliance with all of the standards in order to be an accredited facility. The accreditation cycle is three years. The facility is expected to continue to meet the criteria during the entire time. A self-evaluation form is sent to the facility which completes it and self-reports compliance during the interim years between inspections, along with reporting the required peer review activities.

The standards for JCAHO are incorporated into generic statements for all types of services and patient care activities. AAAHC has delineated standards for specific departments or services, which makes the establishment and review of those departments in compliance with the standards easier to determine. With AAAASF, the focus of the standards is office-based surgery and the requirements are aligned with that more limited focus.

The review of a facility’s activities through the requirements in the”Improving Organizational Performance” section of JCAHO or the “Quality Management and Improvement” section in AAAHC has been developed to look at the services of the organization in a wide variety of ways from quality improvement, peer review, and risk management. The requirements of AAAASF are geared more to retrospective review of clinical activities and Peer Review through the review of six charts per six months or 2% of all cases in a group practice in addition to all unanticipated operative sequelae.

Governance and leadership are addressed in AAAHC in two separate areas by identifying the requirements for the governing body and the administration or leaders of the organization. JCAHO addresses all of the responsibilities in the Leadership (LD) section is more global terms. AAAASF combines governance, administration and patient’s rights into the Governance section and requires that each class of facilities must meet all requirements.

Comparison of AAASF, AAAHC and JCAHO

The major variances in the specifications of the accrediting organizations are:

Y means the issue is addressed in the standards

State Licensure Y Y
Distinct Entity Y Y
Review of Patient Satisfaction Y Y
Cost of Care Reviews Y Y
Report Carding Y Y
Professional continuing education Y Y
Immediate pre-procedure assessment by MD Y Y
Pre-discharge evaluation by physician vague* Y Y
Separate recovery space Y Y not specified
Reappraisal of medical staff^ annual biannual Biannual
Documentation weak strong very strong
Physical Plant weak very strong very strong
Assessment of Patients weak strong very strong+
Continuity of Care weak strong strong
Safety good strong strong
Medical Records fair good good
Confidentiality weak strong strong
Peer Review fair good good
Quality Improvement weak strong very strong
Risk Management strong strong
Compliance with Standards 100% May be < 100% May be < 100%
Term 3 years varies varies
* states use of criteria only , ^minimal interval, +addresses abuse, restraints, advanced directives.