The Joint Commission introduced standards and a survey process for smaller office-based surgery practices in 2001. The Joint Commission’s Office-Based Surgery (OBS) Accreditation Program serves specifically as a quality oversight tool for surgical practices with four or fewer practitioners. More than 400 office-based surgery practices are accredited by The Joint Commission.
Benefits of accreditation
- Demonstrates a commitment to the highest level of patient safety and patient care.
- Eases access to managed care contracts and encourages patient referrals.
- Increases competitive edge.
- Nationally acknowledged benchmark of quality.
- Provides constructive educational opportunity.
- Experienced surveyors offer valuable insights and compliance tips.
- Enhances ability to attract and recruit quality staff.
Eligibility
Surgical practices must meet all of the following criteria to be eligible for accreditation under the office-based surgery standards:
- The organization or practice is composed of four or fewer licensed independent practitioners performing operative or invasive procedures. Multi-site office-based surgery practices are also limited to a combined total of four or fewer LIPs.
- The organization or practice must be physician owned or operated, for example, a professional services corporation, private physician office or small group practice. “Physician” includes dentist or podiatrist.
- Invasive services are provided to patients. (Practices only providing procedures such as excisions of skin lesions, moles, warts and abscess drainage limited to the skin and subcutaneous tissue are typically not surveyed under the OBS standards.)
- Local anesthesia, minimal sedation, moderate sedation or general anesthesia is administered. (Includes laser eye surgery using topical anesthesia.)
Organizations seeking Medicare certification through The Joint Commission (deemed status surveys) must be surveyed under the Comprehensive Accreditation Manual for Ambulatory Care.
Standards
The OBS standards are a customized subset of The Joint Commission’s ambulatory care standards, maintaining the integrity of the ambulatory care accreditation process and ensuring the highest level of patient care and safety. The Joint Commission’s standards address the office-based surgery practice in specific areas, and indicate requirements to ensure that patient care is provided in a safe manner. The Joint Commission develops its standards in consultation with health care experts, providers and researchers, as well as purchasers and consumers. The standards-based performance areas for office-based surgery practices are:
- Environment of Care
- Emergency Management
- Human Resources
- Infection Prevention and Control
- Information Management
- Leadership
- Life Safety
- Medication Management
- National Patient Safety Goals
- Performance Improvement
- Provision of Care, Treatment, and Services
- Record of Care, Treatment, and Services
- Rights and Responsibilities of the Individual
- Transplant Safety
- Waived Testing
The Comprehensive Accreditation Manual for Office-Based Surgery Practices is available for purchase online at http://www.jcrinc.com/, or by calling JCR Customer Service toll free at (877) 223-6866.
Accreditation process
The Joint Commission’s accreditation process concentrates on operational systems critical to the safety and quality of patient care. To earn and maintain accreditation, an office-based surgery practice must undergo an on-site survey by a Joint Commission surveyor every three years. The objective of the survey is not only to evaluate the practice, but to provide education and guidance that will help staff continue to improve the practice’s performance. Surveyors for the OBS accreditation program are health care professionals from the ambulatory care field who have specific knowledge, training and experience in smaller surgery settings. The survey process focuses on evaluating actual care processes by tracing patients through the care, treatment and services they received. In addition to these patient “tracers,” surveyors conduct systems tracers to analyze key operational systems that directly impact the quality and safety of patient care.
Following the on-site survey, the practice will receive a summary of survey findings. The accreditation decision is not made until an organization’s post-survey activities are completed. For more information about the specific components of the accreditation process, go to www.jointcommission.org/AccreditationPrograms/Office-BasedSurgery/AccreditationProcess.
Cost of accreditation
The fee for an office-based surgery survey is $6,950 for a typical one-day survey, and The Joint Commission spreads that cost over a three-year period. If a practice includes more than one site providing surgical services, there is an additional fee of $3,050 for each extra day. For other pricing information, contact The Joint Commission’s Pricing Unit, at (630) 792-5115.
Office-based surgery practice information available to the public
Information about the safety and quality of accredited office-based surgery practices is available to the public on Quality Check®, www.qualitycheck.org. This comprehensive listing includes each accredited surgery practice’s name, address, telephone number, accreditation decision, current accreditation status and effective date, and its most recent Quality Report. Quality Check® also includes organizations that are not accredited by The Joint Commission to provide consumers with more information about where to go for their health care needs. However, Quality Reports are only available for Joint Commission accredited organizations.
For questions about OBS standards, contact the Standards Interpretation Group at (630) 792-5900 or complete the Online Question Form at www.jointcommission.org/Standards/OnlineQuestionForm.
For more information about the Office-Based Surgery Accreditation Program, call (630) 792-5286 or visit the Joint Commission Web site at www.jointcommission.org.