Office Based Surgery Center Accreditation VIP Premium Package

Description

VIP Office Based Accreditation Package

For brand new initial Office Based Surgery Centers (OBS) and those requiring full spectrum consulting, documentation and inspection training.  This premium package is designed for Office Based Surgery Centers preparing for initial accreditation inspection or centers seeking comprehensive support.  You’ll receive personalized, expert guidance from application to inspection and strategic insight needed to pass the first time.  

What’s Included:

A complete Office Based Policy and Procedure Manual

1. Minute Strategy Call

Meet with an accreditation expert to get clarity on the application process

1. Month Access to Accredia TV

Watch on-demand videos and prep guidance to support your team’s readiness

Daily, Monthly, Quarterly and Annual Logs for documentation

Logs to track & document key functions of the office based surgery center

Scheduled Virtual Walk-Through & Mock Inspection Checklist

We’ll walk through your center virtually, pointing out potential red flags and offering tips plus you’ll receive a checklist to keep you aligned

1 Strategy Session via phone, face-time or zoom to review environment and discuss environment logs

1 Strategy Session via phone, face-time or zoom to review Quality Improvement Program, Clinical Records, Medications & Crash Cart Contents, Infection Control Program and Sterilization leading up to the survey.

1 Strategy Session via phone, face-time or zoom to review Credentialing Files and HR Files

Policy and Procedure Manual Chapters & Policy’s are:

Governance

Medical Staff By-Laws

Management Plan

Governing Body Functions

Rules & Regulations

Peer Review Process

Organizational Chart and Committee Relations

Medical Staff Membership

Procedure for Appointment

Corrective Action

Administration

Mission, Vision, Value Statement

Scope of Services / Patient Age

Equal Employment Opportunities

Performance Reviews / Orientation / Per Diem Staff / Registry

Conflicts Of Interest

Discrimination / Sexual Harassment / Abuse

Confidentiality

Consent for Surgery

Informed Consent

Emancipated Minors

Medical Records

Patients’ Bill of Rights

Patient Responsibilities

Patient Information Release

Detention of Patients / Against Medical Advice

Patient Complaints and Grievances

Surgery Scheduling

Liability Insurance Carrier

Advance Directive

Billing Systems

Billing Compliance

Cash & Credit Handling

Compliance Plan

Language Assistance Plan

Observer In Patient Care Area

Dress Code

Change of Provider

Anesthesia Services

Anesthesia Evaluations and Classifications

Anesthesia Classification Grid

Anesthesia Care Post Operatively

Duties of the Anesthesia Provider

Types of Anesthesia Performed

Deeper Than Intended Level of Sedation

Propofol

Removal of Aspirate General Anesthesia

Scope and Standards CRNA

Moderate Sedation training and education for Registered Nurses

Perioperative Care

Non-Approved Abbreviations, 1A Abbreviations

Pre-Operative Phone Call

Pre-Operative Preparation

Accurate Identification of Operative Site

Pre-Operative Requirements

Nursing Assessments

Pre-operative Skin Preparation / Removal of Hair

History and Physical

Visitors

Implant Device Identification

Counts and Guidelines

Laser Safety

Electrosurgical Unit

Admission Assessment for PACU

Care and Monitoring of the PACU Patient

Documentation for PACU

Post-Op Assessment

Aldrete Score

Discharge Guidelines

Anesthesia Discharge Criteria for Recovery Room

Patient Discharge Orders

Respiratory Complications / Airway Management

Hypertension

Pain Assessment

Tissue Exemptions

Latex Allergy Guideline

Needleless Plan

Assessment and Treatment of DVT and PE

CLIA Waived Testing

Medical Laboratory Reports

Snack or Nourishment

Patient and Family Education

Overnight Care

Medications Management

Administration of Medications

Medication Procurement / Out-dates

Medication Storage

Controlled Substances

Drug Disposal & Destruction

Crash Cart Drugs

Labeling Medications

High Alert Look Alike / Sound Alike

Drug & Product Recall

Intravenous Guidelines

Form for Reporting Medication Errors

Refrigerator & Medications

Medication Reconciliation

Prescription Pads

Single Dose Vial, Syringes, Safe Injection Practices

Orders

Multiple Dose Vial Expiration

Quality Improvement

Quality Management and Improvement Plan 

Accreditation

Infection Control

The Infection Control Program

CDC Nationally Recognized Guidelines

Infection Control Attire

Infection Control Attire for Patients

Cleaning the Environment / Schedule

CDC Hand Washing

Communicable Diseases

Surgical Site Infection

Tuberculosis (TB)

Hepatitis Vaccination or Waiver

Influenza Virus Plan

CDC COVID-19

Infection Reporting Data Survey 

Management of Infectious Waste and Linens

Infection Control Supplies

Human Immunodeficiency Virus (HIV)

Blood Body Fluid Spill Clean-up (Spills policy)

Personal Protective Equipment (PPE)

Emergency Management

Adverse Incidents

Sudden Return to the OR

Emergency Transfer

Malignant Hyperthermia

Anaphylactic Shock

Blood

Unexpected Blood Loss

Cardiac Arrest 

CPR

Security / Unauthorized Investigation

Dismissal of Patient from care

Disruptive Behavior

Unruly Patient

Violence in the workplace

Incapacitated Surgeon

Incapacitated Anesthesia Provider

Impaired Surgeon

Impaired Anesthesia Provider

Impaired Healthcare Worker

Medical Emergency Response

Non Medical Emergency Response

Fire and Safety

Safety Management Program

No Smoking

Code Red Fire Response Plan / Fire Extinguisher

Fire Alarm

Fire Watch

Automatic Sprinkler

Impairment Coordinator

Code Brown Bomb Threat

Active Shooter

Medical Equipment Risks

Equipment Malfunctions

Compressed Gas

Emergency Power

Failure of Generator

Failure Commercial Power

Central Supply-Sterilization

Care, Cleaning, Packaging and Sterilization

Sterilization of Implantable and Special Device

Sterilizer Performance Monitoring

Chemical Indicators

Frequency of Biological Indicators

Shelf Life of Commercially Sterilized Items

Disposable Products

High Level Disinfection

Reprocessing of Surgical Devices

Healthcare Workplace Safety Facility Compliance 

Exposure Control Plan (OSHA)

Exposure Determination (OSHA, Blood Borne Pathogens)

Exposure Incident

Exposure Incident Form

Ergonomics Plan

Hazard Communication Plan (OSHA)

Sharps Safety

Fall Prevention

Compressed Gas Flammable & Combustible

Earthquake Safety

Workplace Violence

Fire Risk Assessment

TB Screening

Management of Environment / Culture of Safety Assessment

Daily Logs

Temperature and Humidity

Refrigerator Temperature

Sterilization

High Level Disinfection

Glucose

Pregnancy 

Pregnancy Control Testing

Implant

Eyewash

Narcotic

Specimen

Cleaning

Patient Satisfaction Survey

Monthly Logs

Emergency Checklist

Infection Control Surgeon Reporting

Quarterly Logs

Fire Drills

Peer Review

Governing Board Meeting

Quality Meeting

Hand Hygiene

Infection Control Rounds

Infection Control Surveillance Forms (Hand Hygiene, Multidose Vial, Wiping Septum)

Annual Logs

CPR / Code Blue

Malignant Hyperthermia

Fire Extinguisher Training

Pharmacy Inspection

Receptacle Testing