/"," 
Department of Health and Human 
Services

OFFICE OF

INSPECTOR GENERAL

SURGERY IN OUTPATIENT SETTINGS:

FORMS OF OVERSIGHT

, SERVIC' 
Richard P. Kusserow 
INSPECTOR GENERAL 
ItJrdi/a  APRIL 1992  OFFICE OF INSPECTOR GENERA

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services' (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs. This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components: the Office of Audit Services, the 
Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 
the Secretary of HHS of program, and management problems, and recommends courses to 
correct them. 
OFFICE OF AUDIT SERVICES 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the Department. 
OFFICE OF INSTIGATIONS 
The OIG's Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
AN 
OFFICE OF EVALUATION  INSPECTIONS 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department 
the Congress, and the public. The findings and recommendations contained in these inspection 
reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental programs. 
This report was prepared under the direction of Don McLaughlin, the Regional Inspector 
General for the Office of Evaluation and Inspections, and Jim Wolf, Deputy Regional 
Inspector General, Office of Evaluation and Inspections, Region VII. Participating in this 
project were the following people: 
Kansas City  Headquarters 
Hope Hartshorn, Project Leader  Cathaleen A. Ahern, Program Specialist 
Hugh Owens, Team Leader 
Perry Seaton, Team Leader  Servces 
Department of Health and Human 

OFFICE OF

INSPECTOR GENERAL

SURGERY IN OUTPATIENT SETTINGS:

FORMS OF OVERSIGHT

to" 
.. SERVIC'~o
Richard P. Kusserow 
INSPECfOR GENERA 
~/tdi/a  OEI-07-91-0090  EXECUTIVE  SUMMAR 

PUROSE 
The purpose of this study is to determine the forms and extent of oversight for 
freestanding outpatient facilties in which surgery is performed. 
BACKGROUN 
An increasing number of surgical procedures that were once performed in an acute 
care settng are now being performed in outpatient facilities. This shift in setting is 
due in part to advances in medical technology and the lower cost of outpatient care. 
This shift has raised concerns about the appropriateness of the setting and the quality 
of care. The House of Representatives Small Business Subcommittee on Regulation 
Business Opportunities, and Energy requested this study. 
Surgery can be defined by the invasiveness of a procedure and/or the level of 
sedation/anesthesia required. The definition of surgery varies widely among the 
agencies, boards, and organizations involved in oversight. 
The forms of oversight in place for outpatient facilities include licensure, certification 
and accreditation. Licensure of facilities is performed by individual State health 
facilty licensure agencies. Certification is carried out by the Health Care Financing 
Administration (HCFA). Certification is required for certain tyes of facilties to 
receive Medicare reimbursement. Accreditation is performed by private accreditation 
associations and is usually voluntary on the part of the facilty. Other forms of 
oversight are provided by peer review organizations (PROs), insurance companies, and 
professional medical organizations. 
METHODOLOGY 
We contacted various regulatory bodies, as well as others that might playa role in the 
oversight of outpatient surgical facilities. We received data from most of these 
sources. Our analysis of the data focused on standards that promote 
quality of care in 
a health care setting. This information was compiled into tables for the appendices of 
the report. 
Our review was conducted in accordance with the  Interi Standrds for Inspectins 
issued by the President s Council on Integrity and Efficiency. 
A companion study, "Surgery in Outpatient Settings: A Four-State Study 
(OEI 07-91-01470), is being released concurrently with this report. This inspection 
determined the tyes of surgical procedures which are commonly performed in 
outpatient settings in four States and the extent to which such outpatient settings are 
subject to licensure or accreditation.
 - -- -
FIINGS 
MA 
FACILIES AR NOT SUBECT TO liCENSURE 
Ten States do not license ambulatory surgical centers (ASCs). 
Twenty-two States do not license birthing centers. 
Twenty-six States do not license abortion clinics. 
Forty-two States do not license emergency centers. 
mE LICENSURE STANARS THT EXST VARY FROM STATE TO STATE 
Licensure standards include legal limits on procedures, peer review, training for 
ancilary personnel, written transfer agreements, a minimum staffing requirement, and 
medical records. Other standards include infection control procedures, presence of 
emergency equipment and personnel trained in emergency procedures, anesthesia 
administration, and equipment maintenance. These standards vary greatly from State 
to State.

AN 
ACCREDITATION, CERTIICATION,  PEER REVIEW PROVIE ANOmER 
FORM OF OVERSIGHT 
Accreditation associations apply a set of separate standards which are usually more 
stringent than the licensure agencies require. However, accreditation is usually 
voluntary on the part of the facilty. 
Certification requires that a facility meet certain specific requirements in order to 
display recognition that they meet the standards of the Medicare program. Once 
certified, a facility is eligible to receive reimbursement for care provided to Medicare 
beneficiaries. Only certain tyes of facilities are certified (such as ASCs) and not all 
of the facilities in each category are certified (Le. not all ASCs are certified). 
The Peer Review Organizations (PROs) conduct pre-procedure review for some tyes
of procedures in outpatient settings such as ASCs and health maintenance 
organizations. We are currently conducting an inspection that addresses the role of 
PROs in an outpatient setting. 
LIE 
mERE IS  OR NO OVERSIGHT FOR PHYSICIAS' OFFICES 
The State health facility licensure agencies do not license physicians' offices. State 
medical and podiatry boards regulate a physician s practice through control of the 
physician s license. The State medical and podiatry boards do not address setting
when granting licenses to practitioners. 

ii.  . ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ...  . .  ...  . .. .   ....    ....    ....    .... . ..  ...  
. ..  ..  ..  ..  ..  ..  ..  ..  ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ...   ..  ..  ..  ..  ..  ..  ..  ..  . . . . . .. 
TABLE OF CONTENTS

EXECU SUMY 
INODUCTON 
Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Background 
Methodology  . . . . . . . . . . . . . . . 5 
FIINGS 
Many facilities are not subject to licensure  . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 
The licensure standards that exist vary from State to State  . . . . . . . . . . . . . . . . 7 
Accreditation, certification, and peer review provide 
another form of oversight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
There is little or no oversight for physicians' offices 
APPENDICE 
Definitions of surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A
1989 Part B Medicare Annual Data (BMA) selected procedures 
and number of procedures performed in each setting  . . . . . . . . . . . . . . . . .. B-
Types of facilities and the number of State health facilty licensure 
agencies that license each. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. C-
State health facility licensure agencies standards for licensure  . . . . . . . . . . . . D-
State medical and osteopathic boards standards for licensure  . . . . . . . . . . .. E-
State podiatry boards standards for licensure  . . . . . . . . . . . . . . . . . . . . . . .. F-
Accreditation association standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-
Additional accreditation association standards. . . . . . . . . . . . . . . . . . . . . . . . H INTRODUCTION

PUROSE 
The purpose of this study is to determine the forms and extent of oversight for 
freestanding outpatient facilties in which surgery is performed. 
BACKGROUN 
An increasing number of surgical procedures that were once performed in an acute 
care setting are now being performed in outpatient facilities. This shift in setting 
due in part to advances in medical technology and the lower cost of outpatient care. 
This shift has raised concerns about the appropriateness of the setting and the quality 
of care. One concern is the lack of oversight for most tyes of outpatient surgical 
facilities. Another concern is that some surgical procedures may be inappropriate for 
an outpatient setting due to the high-risk nature of the procedure. Examples of high-
risk procedures in outpatient facilities might include orthopedic procedures such as 
ankle fusions and triple arthrodesis, abortions, liposuction procedures, laparoscopy, 
hernia repair, radical mastectomies, some tyes of plastic surgery, and some tyes of 
eye surgery. 
The House of Representatives Small Business Subcommittee on Regulation, Business 
Opportunities, and Energy requested this study. 
Defitin of Surer 
No Uniform 
Surgery is difficult to classify because several criteria can be used to define it. Surgery 
can be defined by the invasiveness of a procedure and/or the level of 
sedation/anesthesia required. 
The Medicare Carrier Manual definition of surgery is very general and includes the 
terms incision, excision, repair, suture, destruction, introduction, fracture 
manipulation, dislocation, amputation, and endoscopy in the definition. 
The definition of surgery varies widely among the agencies, boards, and organizations 
involved in oversight. These definitions are contained in Appendix A. 
Outit Faci 
Overv of 
Ambulatory surgical centers (ASCs) and outpatient hospital settings are capable 
conducting "major" surgical procedures such as cardiac or vascular catheterization 
trauma care, and hernia repair. According to SMG Marketing, a major marketing 
report firm, the number of procedures performed in ASCs increased more than 100 
percent from approximately 1 milion in 1986 to approximately 2.
2 millon in 1989. 
The most commonly performed procedures in ASCs are ophthalmological procedures;  gyecological surgery; ear, nose, and throat procedures; and orthopedic surgery. 
These make up 65.6 percent of all surgeries performed in ASCs. 
Other outpatient settings, including physician s offices, are sites for relatively "minor 
surgical procedures. Examples of minor surgery include suturing small wounds 
performing skin biopsies, and drawing blood. The Part B Medicare Annual Data 
(BMA) uses the Medicare Carrier Manual' s definition of surgery that is listed on 
page one. According to BMA, the number of surgeries performed in physicians 
offices increased 39 percent from approximately 21.6 milion in 1986 to approximately 
30.0 milion in 1989. 
Selected medical procedures and the number of procedures performed in various 
medical settings based upon 1989 Part B Medicare Annual Data are contained in 
Appendix B. 
Faci  Predes 
and Exmple of 
Type of 
We have classified the tyes of outpatient surgery as minor procedures and major 
procedures. Minor procedures include cleaning and suturing small wounds, drawing 
blood, inserting IV' , performing electromyograms, etc. Major procedures include 
hernia repair, cardiac catheterization, trauma care, vascular catheterization, etc. 
Table 1 on the following page gives tyes of outpatient facilities and examples of 
procedures normally performed in each.  Table 1

Typs of Facities and Exples of Procdures Performed

Faci  Mior Procure  or Procdure

Ambulatory health care clinic

Ambulatory surgical center 
Birthing center 
Health maintenance

organization (HMO) 
Urgent/immediate care center 
Cancer treatment center 
Cardiac catheterization lab 
Emergency center 
Home health care agency 
Independent clinical lab 

Abortion clinic 
Diagnostic imaging center 
Office surgery center 
Physician s office 
Form of Overght 
The principal forms of oversight in place for outpatient facilities which perform 
surgery are licensure, certification, and accreditation. For our purposes, a license 
implies that a facilty or person has met certain specific requirements and has been 
granted permission to provide servce. Licensure, when it exists, is required rather 
than voluntary, and falls under the jurisdiction of State health facilty licensure 
agencies. Certification of a facility involves meeting certain specific requirements in 
order to be reimbursed by the Medicare program. The HCFA certifies certain tyes 
chooses not to seek certification, physicians can stil 
of facilties. If a facilty  be paid 
for professional servces rendered there, but the facilty will not receive a fee. 
Accreditation involves meeting standards set forth by an accreditation association. 
Accreditation is usually voluntary on the part of the facility, and occurs after licensure. 
Accreditation does not take the place of licensure or certification, but may act as a 
supplement or grounds on which to certify.  Other forms of oversight are provided by peer review organizations (PROs), insurance 
companies, and professional medical organizations. 
The PROs review the quality of medical servces provided to Medicare beneficiaries in 
certain settings such as ASCs. They playa role in the internal quality assurance of 
ASCs by reviewing samples of cases and procedures. 
The current Scope of Work, as defined 'in the PROs' contract with HCFA, does not 
require a review of the servces provided in a physician s office. However, HCF A 
does have contracts for two pilot projects currently in progress which address peer 
review of servces provided in a physician s office. The Delmarva Foundation 
(Maryland PRO) is working on a pilot project with two PROs which will review the 
care that physicians provide in an office setting. This is a three year project that 
started September 1, 1990. The other project, The Wisconsin Ambulatory Review 
Project (WARP), involves seven PROs. This project will develop and assess a system 
for monitoring the quality and cost effectiveness of ambulatory medical care for office-
based practices. The WARP began December 1, 1989 and was scheduled to last for 
two years. The contract for this has been extended through November of 1992. 
Insurance companies provide a form of oversight through underwting 
and/or facilities. We contacted 
malpractice/liabilty insurance for individual physicians 
a major insurance company that has general criteria for insuring physicians and 
facilties. The insurance company s coverage criteria included information about 
training, structure of the organization, staffing, servces provided, licensing, practice 
restrictions, hospital privileges, jurisdiction of practice, risk management program 
(mainly for facilties), information on the physical plant, emergency procedures in 
, and claim information. There are 
place at day surgery centers specific criteria for 
determining insurability for surgical procedures. For physicians these criteria included 
training, specialty, and servces performed. For facilties these criteria included staff 
(tyes of professionals and their expertise), equipment, training, and risk management 
in relation to the servces provided. 
Professional medical organizations may be a certifying body (for a specific branch of 
medicine) or they may be a membership body. The six professional medical 
organizations that we contacted have a set of ethical standards for members. Five 
the organizations have educational guidelines for their members. Three of the 
professional organizations have an informal relationship with PROs and two of these 
organizations also have an informal relationship with State boards. None of the 
professional organizations perform a direct monitoring or oversight role. One 
organization indirectly provides oversight through its requirement for continuing 
medical education. Four of the organizations have received patient complaints and 
took action on them.  METHODOLOY 
We contacted every State health facility licensure agency and every State medical 
osteopathic, and podiatry board. We contacted three accreditation associations: the 
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the 
(AAC), 
Accreditation Association for Ambulatory Health Care  and the 
Accreditation Association for Podiatric Surgical Facilities (AASF). We contacted five 
PROs: California Medical Review, Inc., the Florida Professional Foundation for 
Health Care, Louisiana Health Care Review, Rhode Island Health Care Review, Inc. 
and the Wisconsin Peer Review Organization. In addition, we contacted six 
professional medical organizations: the American Academy of Family Physicians, the 
American Board of Podiatric Surgery, the American Board of Surgery, the American 
College of Surgeons, the American Osteopathic Association, and the Association of 
American Physicians and Surgeons. The insurance company that we contacted was 
the St. Paul Fire and Marine Insurance Company, a major malpractice insurer. 
We received data from most of the agencies, boards, and organizations. Our analysis 
focused on standards that promote quality of care in a health care setting. These 
included review of State health facility licensure requirements, review of State medical 
and podiatry board requirements for licensure of physicians and podiatrists, and review 
of accreditation association requirements for accreditation of outpatient facilities. 
We contacted the primary health facility licensure agency in each State. Several States 
have different departments or offices within the agency or State government that 
provide licensure. 
We analyzed narrative responses and the rules and regulations from the States. 
conducted discussions with staff members of appropriate agencies, boards, and 
associations. We also analyzed the responses from the professional medical groups 
PROs, and the insurance company. 
Our review was conducted in accordance with the 
 Intri Standrds for Inspectins
issued by the President s Council on Integrity and Efficiency. 
A companion study, "Surgery in Outpatient Settings: A Four-State Study 
(OEI-07-91-01470), is being released concurrently with this report. This second study 
determined the tyes of surgical procedures which are commonly performed in 
outpatient settings in four States and the extent to which such outpatient settings are 
subject to licensure or accreditation.
 FINDINGS

MA 
FACILIES AR NOT SUBECT TO LICENSURE 
Ten of the States do not license ASCs. Twenty-two of the States do not license 
birthing centers. Twenty-six of the States do not license abortion clinics. Forty-two of 
the States do not license emergency centers (these facilities have the capabilty for 
emergency life support and stabilzation). As reflected in Tables 1 and 2, all of the 
facilities listed above conduct major procedures. 
Several of the facility categories may not exist in all States. Some States do not 
license certain facilties because there are so few of them. Classification of facilities 
also differs among the States; i.e. one State may categorize a facilty as a birthing 
center while a neighboring State may categorize it as an ASC. 
Table 2

Typs of Freestadig Facities and Number of States That License Each

Facity  Number of States That License

Ambulatory surgical center * 
Home health care servce 
Birthing center *

Abortion clinic * 
Independent clinical lab 

Health maintenance organization 
Ambulatory health care clinic 
Emergency center * 
Cardiac catheterization lab * 
Urgent/immediate care center 
Cancer treatment center 
Diagnostic imaging center * 
Office surgery center

Physician s office

Facilities that perform Major Procedures
 Additional information on State licensure is included in Appendix C. 
mE LICENSURE STANARS THT EXST VARY FROM STATE TO STATE 
There are a number of standards that promote quality of care in a health setting. 
These standards are utilized by several State health facilty licensure agencies, medical 
boards, and podiatry boards. 
A particular standard may not apply to all tyes of facilities. The following is a 
summary of the chief tyes of standards that exist. 
Patit 
Complaints  - The State health facilty licensure agency requires the 
1. 
facilty to have a system to receive patient complaints in: 
31 of the 51 States. 
Leal Limits - Guidelines for care (including surgical procedures) in an 
2. 
outpatient setting are set by: 
46 of the 51 State health facility licensure agencies 
26 of the 63 State medical boards 
48 of the 50 State podiatry boards.

Licensure agencies, State boards, accreditation associations, and insurance 
companies usually let the facilities set their own guidelines for procedures which 
would be performed in the facilty. 
Rev 
Peer  - The State health facilty licensure agency requires the facility 
3. 
to have some form of peer review as part of the internal quality assurance 
program in: 
34 of the 51 States. 
Anry 
Training for  Personnl  - The State health facilty licensure agency 
4. 
requires training and/or certification of ancilary personnel (i.e. lab technicians 
or nurses aides) in: 
41 of the 51 States. 
Credtiling Proces - The State health facility licensure agency requires 
5. 
each facilty to have a separate credentialing process. Each facility must review 
the education, training, and background of their professional personnel in: 
43 of the 51 States.  Predes 
Infectin Contrl  - The State licensure authorities require that 
6. 
procedures to prevent the spread of infection are part of the daily operation of 
an outpatient surgical facility. Training in infection control procedures is often 
part of in-servce training and/or continuing education. Infection control 
procedures are required by: 
41 of the 51 State health facilty licensure agencies

28 of the 63 State medical boards 
26 of the 50 State podiatry boards.

The training and residency process for most physicians and podiatrists often 
includes infection control procedures. For this reason, most medical and 
podiatry boards do not cover this in the 
licensure process. 
Medical Training Standrd  - The State licensure authorities have established 
requirements for the education, training, and background for 
physicians that 
perform surgery in an outpatient setting in: 
45 of the 51 State health facility licensure agencies 
32 of the 63 State medical boards 
30 of the 50 State podiatry boards.

Licensure agencies, State boards, insurance companies, and accreditation 
associations often let the facilities set up their own screening process for 
physicians. The medical and podiatry boards do not address setting when 
granting a permanent unrestricted license which is the most common 
tye of
license. 
Transer Ageemt  - The State health facility licensure agency requires a 
8. 
written patient transfer agreement between the outpatient surgical facility and a 
hospital in: 
43 of the 51 States. 
Minim  Reqemt 
Staff  - The State health facility licensure agency 
9. 
requires the presence of an adequate number of specialized personnel in an 
outpatient surgical facility during hours of operation in: 
44 of the 51 States.  10. Emeen Eqpmt and Trin Peronnl  - The State requires the 
presence of emergency equipment and personnel trained in emergency 
procedures to be on-site in an outpatient surgical facilty. Some State medical 
and podiatry boards require applicants for licensure to demonstrate knowledge 
of emergency procedures such as cardiopulmonary resuscitation. Emergency 
equipment and trained personnel are required by: 
44 of the 51 State health facilty licensure agencies

24 of the 63 State medical boards 
19 of the 50 State podiatry boards.

The training and residency process for most physicians and podiatrists usually 
includes a demonstration of knowledge of emergency procedures. For this 
reason, most medical and podiatry boards do not cover this in the licensure 
process. 
Minim Record-Keeping Standrds  - The State health facility licensure 
11. 
agency requires the outpatient surgical facilty to have minimum record-keeping 
standards in: 
47 of the 51 States. 
Anethe Standrd - The State health facility licensure agency requires 
12. 
that trained personnel, such as an anesthesiologist, or certified registered nurse 
anesthetist who is under the supervsion of a qualified physician, administer 
anesthesia in: 
46 of the 51 States. 
Eqipmet Standrds - The State health licensure agency requires regular 
13. 
inspection of calibrated equipment such as x-ray machines in: 
44 of the 51 States. 
Several States are now preparing legislation that will provide or increase oversight of 
these outpatient facilties. One State has indicated that it has the legislative authority 
to license facilities, but does not have adequate personnel or funding to carry out a 
licensure program. 
Additional information on the licensure standards of the various State agencies and 
boards is included in Appendices D, E, and F.  ACCREDITATION, CERTIICATION, AN PEER REEW PROVIE ANOmER 
FORM OF OVERSIGHT 
Accreditation associations apply a set of separate standards which are usually more 
stringent than the licensure agencies require. However, accreditation is usually 
voluntary on the part of the facilty. 
The three accreditation associations that we contacted apply the thirteen standards 
that promote quality of care in a health setting that are listed in the previous finding. 
Additional information on the accreditation associations and the standards that they 
apply is included in Appendix G. 
Additional information on the accreditation associations' policies for unannounced or 
unscheduled visits and public release of information is included in Appendix H. 
Certification requires that a facilty meet certain specific requirements in order to be 
reimbursed by the Medicare program. Only certain tyes of facilties are certified 
(such as ASCs) and not all of the facilties in each category are certified (Le. not all 
ASCs are certified). 
The PROs perform pre-procedure review for some  in outpatient 
tyes of procedures 
settings such as ASCs and HMOs. We are currently conducting an inspection that 
addresses the role of PROs in an outpatient setting. 
mERE IS LlIE OR NO OVERSIGHT FOR PHYSICIAS' OFFICES 
The State health facilty licensure agencies do not license physicians' offices. State 
medical and podiatry boards regulate a physician s practice through control of the 
physician s license. The facility in which the physician practices may impose additional 
restrictions upon the physician s practice. The State medical and podiatry boards do 
not address setting when granting 
licenses to a practitioner. 
The HCF A has established a list of covered surgical procedures for ASCs. The 
HCF A reimburses ASCs based upon this list of covered procedures. There is no list 
of this tye for physicians' offices. 
The PROs have no current authorization to review the care provided in a physician 
office. We found that PRO review of physicians' offices includes only the two 
previously described pilot projects currently in progress.  APPENDIX A

DEFIONS 
OF SURGERY 
On of  accreditation associations that we contacted had a definition 
the Thee 
surgery. 
Surgical and Anesthesia Servces - those surgical or other invasive procedures 
for which patients receive general, spinal, or major regional anesthesia or 
sedation/analgesia either by intravenous, intramuscular, or inhalation methods 
that, in the manner used, may result in the loss of the patient's protective 
reflexes. Invasive procedures include, but are not limited to, percutaneous 
aspirations and biopsies, cardiac and vascular catheterizations, and 
endoscopies. " 
insurance company s definition of surgery is: 
On 
- No Surgery - no surgical procedures performed other than circumcisions 
incision of boils and superficial abscesses or suturing of skin and superficial 
fascia. Includes closed fractures of the fingers and toes. 
- Assisting in Surgery - assisting in surgery on physician s own patients 
including closed bone fractures, except those of the finger and toes, and D&C' 
or vasectomies performed under local anesthesia. 
- All Other Surgery - includes operations in or upon any body cavity, including, 
but not limited to the cranium, thorax, abdomen, or pelvis; any other operation 
which, because of the condition of the patient or the length or circumstances of 
the operation presents a distinct hazard to life. It also includes: removal of 
tumors, open bone fractures, amputations, abortions, caesarean sections, the 
removal of any gland or organ, plastic surgery, tonsilectomies, adenoidectomies 
and any operations done using general anesthesia." 
of the professional organizations that we contacted had a definition of 
None  surgery. 
of the PROs that we contacted had a definition of surgery. 
AU 
Surgery - (a.) that discipline of health care delivery utilizing the knife, cautery, 
mcryogenicse, or cthemhicals,o (b.) indvasives proc.ed"ures  to remove, correct, or 
faciltate the cure of a disease, process, or injury, and (c.) that branch of 
medicine which treats diseases, injuries, and deformities by manual or operative
A 
 Surgery - all invasive procedures are considered surgery. Anything that can 
affect the diagnostic related groups (DRG) assignments. II 
Surgery - any procedure that changes the Medicare reimbursement rate. 
Certain procedures done would affect the DRG' s which would impact upon the 
Medicare reimbursement rate. Other procedures done would have no effect." 
Surgery - for outpatients, all surgery that has a CPT -4 code and is also on 
HCF A' s list of covered surgical procedures. 
Surgery (outpatient) - anything that is on the HCF A list of covered procedures 
for ASCs. This may 
include procedures not normally considered to be surgery 
such as upper GI's, colonoscopy, and endoscopy. All cases are selected 
according to this list of procedures. 
51 State health licensure agencies that we contacted had a 
Seven of the 
 definition for 
surgery. 
Surgery - treatment of human beings by a physician, by the use of one or more 
of the following procedures: cutting into any part of the body by surgical 
scalpel, electro-cautery, or some other means for diagnosis or removal of 
foreign bodies; reduction of fractures or dislocations of a bone, joint, or bony 
structure; repair of malformations or body defects resulting from injury, birth 
defects, or other causes that require cutting and manipulation or suture; 
instrumentation of the uterine cavity including the procedure commonly known 
as a D&C for diagnostic or therapeutic purposes; any instrumentation of or 
injection of any substance into the uterine cavity of a woman for the purpose of 
terminating a pregnancy; human sterilization procedures; or endoscopic 
procedures. " 
Surgery - treatment of conditions by operative means, involving incision or 
repair of human tissues. 
Surgery - 'oscopy' procedures.. are considered ' surgical' procedures within the 
context of the ASC provision. Also, surgical procedures are commonly thought 
of as those involving an incision of some tye, whether done with a scalpel or 
(more recently) a laser, followed by removal or repair of an organ or other 
tissue:' 
Surgery - while recognizing that surgery may include some nonoperative 
modalities, in the context of these regulations surgical servce refers to the 
management of localized diseases and/or conditions by operative means which 
include peri-operative and operative treatment and the conditions outlined in 
Section 21.4 herein. 
A  Surgery - any manual or operative procedure performed upon the body of a 
living human being for the purpose of preservng health, diagnosing or curing 
disease, repairing injury, correcting deformity or defect, prolonging life or 
relieving suffering, and involving any of the following: incision, excision, or 
curettage of tissue or an organ; suture or other repair of tissue or an organ 
Qpen reduction of a fracture; extraction of 
including a closed as well as an 
tissue including the premature extraction of the products of conception from 
the uterus; or an endoscopic examination with use of a local or general 
anesthetic. 
Surgery - ..severing or penetrating of tissues of human beings. 
Surgery - pathological process for the surgical care shall be localized and not 
conducive to system disturbance. 
63 State medical and osteopathic boards that we contacted had a definition 
Four of the 
of surgery.

Surgery - to sever the tissues of the body for the purpose of penetration for 
treatment, replacement, or removal of afflcted parts. The simple piercing of 
the skin by the insertion of a solid wire or needle (acupuncture) not intended to 
separate or sever tissue for the purpose of treating by acupuncture is not 
surgery as term is used in the Healing Arts Act."

Surgery (osteopathic) - the use of any and all methods in the treatment of 
disease, injuries, deformities, and all other physical and mental conditions in 
and of human beings, including the use of osteopathic manipulative therapy. 
Surgery - the diagnosis or treatment of or operation or prescription for any 
human disease, pain, injury, deformity, or other physical or mental condition. 
Surgery - .. to penetrate, pierce, or sever the tissues of a human being... 
State podiatry boards that we contacted had a definition for surgery. 
Six of the 50 
Surgery - ".. to penetrate, pierce, or sever the tissues of a human being.. 
Surgery - use of any cutting instrument to treat a disease, ailment, or condition 
of the human foot as defined herein, except that a podiatrist shall not be 
authorized to amputate the human foot, or perform any surgery on the human 
body at or above the ankle joint, or administer anesthetics other than local 
anesthetics. " 
A  Surgery - practice of medicine and surgery means the diagnosis or treatment of 
or operation or prescription for any human disease, pain, injury, deformity, or 
other physical or mental condition. 
Surgery - conditions that require operative procedures. 
Surgery - the surgical treatment of the foot, but shall not include the 
amputation of foot or leg, surgery of the leg, or use of any anesthetic other 
than local anesthetics, except that a podiatrist may administer narcotics and 
medications in the treatment of ailments of the human foot and leg in the same 
manner as a physician and surgeon. 
Surgery - use of any cutting instrument to treat a disease, ailment, or 
condition. 
A 
 APPENDIX 

1989 PART B MEICAR ANAL DATA SELECfD PROCEUR
AN NUER 
OF PROCEDUR PERORMD IN EACH SETTG 
Ambulatory 
Hospita  Hospita  Surgica  Physician
Procdure  Inpatient  Outpatient  Center  Ofce 
Incision and 
drainage  700  600  200  666 800 
Skin biopsy  600  700  300  869 800 
Excise benign 
lesion  700  000  900  880 200 
Excise 
malignant 
lesion  200  700  600  302 200 
Debride nails  500  700  100  141 300 
Destruct lesion  500  900  100  505 000 
Arhrocentesis  600  200  200  878 900 
Total hip

replacement *  000  100  300 
Coronary artery 
bypass *  121 200  100 
Endoscopy  434 400  309 700  300  700 
Colonoscopy  251 200  464 900  400  121 900 
Dilate urethra  200  600  209 000 
Cataract 
removal  900  709 900  166 900  400 
* The numbers that are less than 2 000 have a very high percentage of error.  APPENDIX C

TYES OF FACILITIES AN TH NUER OF STAlE HEALTH FACILIT 
LICENSUR AGENCIE THT LICENSE EACH 
C - 1
 unclenr nnd the reader should refer to the enclosed foolDotes for grea.er demil indicates the licensure of the facilities in a given of many or 311lus St:1tc :'re  detnil given State and the reader should refer to the enclosed (oOtnotes for gre:uer indicmes there are conditions thnt relate to licensure of this fj-pe of facilry in a  facility does noc exist in the State tye of a blank indicate! the State does not license that type of facility or that  facility indicues the primary licensure agency in that State does license that typc of  Physici Offce  nter Offce Surgery Ce Diagnostic rmaging Center  Abortion Clinic  Independent Clinical Lab  Home Health Care Agency  nter Emergency  Cardiac C::thetenZ3tion Lab  Tre:ltm Cc:ntcr Cancer nt  Center Urgent/Immediate C:uc
 Orgnniwtion He:llt'" Maintenance  Birthing Center  cal Conter Ambulatory Surgi Oinic Ambulntory Henlth Cnre  FACl TYES OF  TY
E
S
 O
F
F 
A
U
O
C
EU
S 
UAN
 AD
G T
ENIlE
C N
IU
 TM
HE
TR
  O
UF
CE ST
SA
ET
 E
EA H
CE
HA
 T
H
F 
A
C
l FACI AN  FACI

TYES OF  TH NUER OF STATE HETH 
LICENSUR AGENCIE THT UCENSE EACH 
FACIIT 
TYES OF  STATE 
Ambulatory Health Care

Clinic 
Ambulatory Surgical Center 
Birthing Center 
Health Maintenance 
Organization 
Urgent/lmmediate Care

Center 
Cancer Treatment Center

Cardiac Catheterization Lab 
Emergency Center 
Home Health Care Agency 
Independent Clinical Lab 
Abortion Clinic 
Diagnostic Imaging Center 
Offce Surgery Center

Physician s Office 
indicates the primary licensure agency in that State does license that tye of 
facility 
a blank indicates the State does not license that tye of facility or that 
tye of
facilty does not exist in the State 
indicates there are conditions that relate to licensure of this tye of facilty in a 
given State and the reader should refer to the enclosed footnotes for greater 
detail 
indicates the licensure status of many or all of the facilties in 
a given State are 
unclear and the reader should refer to the enclosed footnotes for greater detail 
C - 3
 FACl AN  FACI 
TYES OF  TH NUER  HETH 
OF STAll 
LICENSUR AGENCI THT UCENSE EACH 
FACl 
TYES OF  STATE 
Ambulatory Health Care

Clinic 
Ambulatory Surgical Center 
Birthing Center 
Health Maintenance 
Organization 
Urgent/lmmediate Care

Center 
Cancer Treatment Center

Cardiac Catheterization Lab 
Emergency Center 
Home Health Care Agency 
Independent Clinical Lab 
Abortion Clinic 
Diagnostic Imaging Center 
Offce Surgery Center

Physician s Offce 
indicates the primary licensure agency in that State does license that 
tye of
facilty 
a blank indicates the State does not license that tye of facilty or that 
tye of
facilty does not exist in the State 
indicates there are conditions that relate to licensure of this tye of facility in a 
given State and the reader should refer to the enclosed footnotes for greater
detail 
indicates the licensure status of many or all of the facilities in a given State are 
unclear and the reader should refer to the enclosed footnotes for greater detail 
C - 4
 FACI AN TH NUER  HETH FACl

TYES OF  OF STATE 
LICENSUR AGENCIE THT LICENSE EACH 
FACIIT 
TYES OF  STATE 
Ambulatory Health Care 
Clinic 
Ambulatory Surgical Center 
Birthing Center 
Health Maintenance 
Organization 
UrgentlImmediate Care

Center 
Cancer Treatment Center

Cardiac Catheterization Lab 
Emergency Center 
Home Health Care Agency 
Independent Clinical Lab 
Abortion Clinic 
Diagnostic Imaging Center 
Offce Surgery Center

Physician s Offce 
indicates the primary licensure agency in that State does license that 
tye of
facilty 
a blank indicates the State does not license that tye of facilty or that 
tye of
facilty does not exist in the State 
indicates there are conditions that relate to licensure of this tye of facilty in a 
given State and the reader should refer to the enclosed footnotes for greater 
detail 
indicates the licensure status of many or all of the facilties in a given State are 
unclear and the reader should refer to the enclosed footnotes for greater detail 
C - 5
 FACI AN 
TYES OF  TH NUER  HETH FACIIT

OF STATE 
UCENSUR AGENCI mAT LICENSE EACH 
FACI 
TYES OF  STATE 
Ambulatory Health Care

Clinic 
Ambulatory Surgical Center 
Birthing Center 
Health Maintenance 
Organization 
UrgentlImmediate Care

Center 
Cancer Treatment Center

Cardiac Catheterization Lab 
Emergency Center 
Home Health Care Agency 
Independent Clinical Lab 
Abortion Clinic 
Diagnostic Imaging Center 
Offce Surgery Center

Physician s Offce 
indicates the primary licensure agency in that State does license that 
tye of
facilty 
a blank indicates the State does not license that tye of facilty or that 
tye of
facilty does not exist in the State 
indicates there are conditions that relate to licensure of this tye of facilty in a 
given State and the reader should refer to the enclosed footnotes for greater
detail 
indicates the licensure status of many or all of the facilties in 
a given State are
unclear and the reader should refer to the enclosed footnotes for greater detail 
C - 6
 FOOTNOTE FOR TYES OF FACI AN TH NUER 
RETI FACI  OF STATE
LICESUR AGENCI THT 
LICENSE EACH 
Arizona - The Department of Insurance licenses HMOs. 
California - Most, if not all, of the ASCs in the State are certified while fewer than 
50% of them are licensed. Licensure and certification standards are the same for 
ASCs. Licensure of Birthing Centers and Abortion Clinics may be provided as a 
servce under a primary care clinic license (Le. a primary care clinic is non-profit and
the patients served are Medi-Cal eligible). The State of California Department of 
Corporations licenses HMOs. The Department of Health Servce s Laboratory Field
Servces program licenses Independent Clinical Labs. 
Colorado - The Colorado Division of Insurance must grant a certificate of authority
to HMOs in order to operate legally in the State. The Health Facilities Division 
has a 
role in regulation as the designee of the Executive Director of the Colorado 
Department of Health. 
Florida - The State is currently 
revising their licensure statutes. 
Georgia - The Health Care Section of the Georgia Department of Human 
Resources licenses only the home health care servces that hold themselves out to the 
public as Home Health Care Agencies (when care is being provided by private nursing 
servces ). 
Idaho - The State licenses Home Health Care Agencies if they are for-profit
organizations. The State Department of Health and Welfare conducts Medicare 
certification surveys for Ambulatory Surgical Centers and 
Independent Clinical Labs. 
Ilinois - Abortion Clinics and Offce Surgery Centers may be licensed if they meet 
rules set out for ASCs. Home Health Agencies are licensed by the Ilinois 
Department of Public Health. 
Iowa - The Department of Inspections and Appeals has a task force lookig at the
issue of licensure for ASCs. This would apply only to those ASCs where the recovery 
period is over 24 hours. The State Health Facilties Division conducts Medicare 
certification surveys for Ambulatory Surgical Centers. 
Kansas - The State regulates labs through Medicare certification and CLIA. 
Licensing is done only for laboratories testing for  controlled substances, and pre
natal syphils. The Department of Health and Environment, Division of Health may
license an Abortion Clinic as an ASC under certain conditions. The State 
does not 
have separate licensing statutes pertaining to Abortion 
Clinics. 
C 
 Maine - The Bureau of Insurance is responsible for licensure of HMOs. The Health 
and Environmental Testing Laboratory is responsible for licensure of Independent 
Clinical Labs. The Division of Health Engineering, Bureau of Health is responsible 
for licensure of Diagnostic Imaging Centers. 
Maryland - The Department of Health and Mental Hygiene licenses

Urgent/lmmediate Care Centers if they use the term "urgent" or "emergency" in their

advertising. Cardiac Catheterization Labs are licensed only if equipment acquisitions

costs were over $600 000. Emergency Centers are licensed only if they use the term

emergency" or "urgent" in their advertising. Diagnostic Imaging Centers are licensed 
only if equipment acquisition costs were over $600 000. The State conducts Medicare 
certification surveys for Ambulatory Surgical Centers. 
Massachusetts - The Department of Public Health, Division of Health Care Quality 
licenses Ambulatory Health Care Clinics, ASCs, HMOs, Urgent/lmmediate Care 
Centers, Cancer Treatment Centers, Emergency Centers, Diagnostic Imaging Centers 
and Abortion Clinics if they meet the statutory definition of a "
clinic. 
Michigan - The Department of Public Health has a licensure program for 
freestanding outpatient surgical facilities, which includes some pregnancy termination 
activities. 
Minnesota - The Department of Health, Health Maintenance Organization Unit 
licenses HMOs. The Health Resources Division of the Department of Health are in 
the process of promulgating licensure rules for Home Health Care Agencies. The 
Radiation Control Section, Environmental Health Division, in the Department of 
Health licenses Diagnostic Imaging Centers. 
Missouri - The State has licensing laws that are applicable to ASCs, Abortion 
Clinics, and Home Health Care Agencies but the Department of Health is responsible
for licensure of only ASCs and Abortion Clinics. The ASC licensing law encompasses 
Birthing Centers but at present time they are not being licensed. 
Montana - The Department of Health and Environmental Sciences licenses Offce 
Surgery Centers if they are multi-specialty group practices. 
Nebraska - The State is preparing to revise outpatient health care clinic standards 
for facilties such as ASCs. 
New Hampshire - State statutes are currently under revision and will change
dramatically in the next year. Currently all outpatient facilties are under the same set 
of standards.

C - 8
 -- 
New Jersey - The State Department of Health licenses only Medicare-certified 
Home Health Care Agencies. If a physician acquires equipment which is subject to a 
health planning/certificate of need requirement, licensure of the equipment is required. 
(New statutory requirement 7/91) 
New York - The Bureau of Hospital Servces, State Department of Health licenses 
Cardiac Catheterization Labs. The Bureau of Home Health Care Servces, State 
Department of Health licenses Home Health Care Agencies. The Wadsworth Center 
for Laboratories, State Department of Health licenses Independent Clinical Labs. 
North Carolina - The Division of Facilty Servces, Department of Human Resources 
licenses Offce Surgery Centers if they meet the definition of ASCs. There are two 
Birthing Centers in the State that are licensed as ASCs. 
North Dakota - The State Department of Health is responsible for licensure of 
outpatient facilities (to exclude physicians' offices). Of these outpatient facilities that 
are licensed, Home Health Care Agencies are the only one that are mentioned by 
name. Present licensure rules do not include any program standards. Outpatient
facilities for purpose of licensure have not been further defined at this point in terms 
of specific servces or tyes of programs. 
North Dakota - Freestanding outpatient facilties that are not 
part of a private 
practice can be licensed. These licensed facilities have facilty standards but no 
program standards. The State Department of Health 
conducts Medicare certification 
surveys for Ambulatory Surgical Centers. 
Ohio - All HMOs are licensed by the Department of Insurance after being certified 
by the Department of Health. The State Department of Health conducts Medicare 
certification surveys for Ambulatory Surgical Centers. 
State). 
Oklahoma - Legislation on licensure of Birthing Centers is pending. Laboratories 
are licensed (there are less than 20 of these in the
that test for the presence of  HN 
Oregon - The State has Type I and Type II facilties in the State. The standards are 
the same for both except for 
physical plant standards. 
Rhode Island - The Department of Business Regulation licenses HMOs. 
South Carolina - The Department of Insurance licenses HMOs. Birthing Centers 
are licensed by the State for deliveries by midwives. The State licenses Abortion 
Clinics that perform second trimester abortions. 
Utah - The authority has been given to license HMOs but there is no program in
place. 
C - 9
 --- - 
Vermont - There are very few outpatient facilties in Vermont other than 
Medicare/Medicaid certified providers which are affilated with hospitals. Any other 
outpatient facilties that exist provide very limited servces. 
Vermont - The State Agency of Human Servces conducts Medicare certification 
surveys for Ambulatory Surgical Centers. 
Washington - The Home Health and Rehabiltation Survey Section of the State
Department of Health licenses Home Health Care Agencies. The Laboratory 
Quality
Assurance Division of the State Department of Health licenses 
medical test sites. The 
Radiation Protection Division of the State Department of Health licenses radiation 
equipment for Diagnostic Imaging Centers and all other facilties with 
x-ray
equipment. The Department of Health, Licensing Cluster includes both facilty and 
professional licensing programs. Facilties with x-ray, nuclear, medical test sites (lab),
and pharmacy operations are subject to these licensure requirements. 
The State 
Department of Health conducts Medicare certification surveys for Ambulatory Surgical 
Centers. 
West Virginia - The Insurance Commission licenses HMOs. The Offce of Health 
Facilty Licensure and Certification conducts Medicare certification surveys for
Ambulatory Surgical Centers. 
Wisconsin - The State Division of Health conducts Medicare certification surveys for
Ambulatory Surgical Centers, Home Health Care Agencies, and Independent Cliical
Labs. 
Wyoming - In 1989 the WY Legislature passed a comprehensive Health Facilty 
licensure bil but did not appropriate staff or funds to implement the law. The
Department of Health has licensure authority which has not been implemented for 
Ambulatory Health Care Clinics, ASCs, Birthing Centers, Urgent/lmediate Care 
Centers, Emergency Centers, Home Health Care Agencies, and Diagnostic Imaging
Centers. They are not responsible for licensing the remainder of the facilities. 
Wyoming - The State Public Health Laboratory licenses laboratories. The Stat 
Department of Health conducts Medicare certification surveys for Ambulatory Surgical 
Centers. 
c;  - 10  APPENDIX D

HETH 
STATE  FACILIT LICENSUR AGENCIE 
STANARS FOR LICENSUR 
D -
 E'Planation of ranking' (I, 2, or 3) i, on page' D-, D-8, and D we u,ed HMO standard,. No 'tandard, apply for Vennont or Wi,cunsin. Virginia, and Wyoming. we u,ed Birthing Center 'tandards, For Maryland and Ohio Dakota. we u,ed Home Health Care Agency standard,. For Iowa, Washington. West States, we used Ambulatory Surgical Center licensure stand:uds. For Idaho and Nonh We have included oniy one ,et of licen,ure standard, lor each Stale, For 41 of the  perfonned. smndards listed above relate: to outpatient facilties where surgery is lice The sure  1 2 11 ! 1 I 2 i I II 11 ren 1 11 11 11 licensure 1111111 wal '111111 1 i 1 : I! 3 : 2 ! 1 11 ! 1 11 11 I, ! Z ! 1 2 I' I I 11 11 " 1 : 1 i , : 1 I 1 I 1 - I ! 1 ; I 1 11 II : 1 1 ' 1 I credemialing process 13 11 12
! 3 I I 3:3;2, 111
1 3 Require facilty to have  1 z ll 12 ancilary personnel 1 1 ! 3 ! z Trnininglcc:rtifcation for 1 21 3 13:31313!3! 3 i 3! 3! 3; 313 3;1\3131313 Record-keeping standards 313:313;3!3\313 31312131312 3131112:2 3IzI3 3iJ lr3: ' 1 : 3 I qualifed personnel ! 3 ! 3 ! 2 ! 1 1 3 ! 2 1 3 ! 1 !2 ! 2 1 I ! 2 ! 2Anesthesii: administered by i 3 I 2 I 3 Equipment standard, 21212121312! zl3 :2 '2; 1 IZ\Z:2: 2IzI2:2!31113121212 2IzI3IzII12 212;3; 3 21212: 2:2;Z:2; 111 2: 1
1212121213131313 Transfer 3greemenlS 3!3 ' 3 113!2121 113\2 3!3'21212'2 211121211!21213!2:1!112 3!2 112.
0 !
1213121113111312: 11312:2 ' 1\1131,lz Peer review 2!3 1: 11z121312! 11112 212 3 I 3
3 11 I 2 3: 3 I 2 i 2 ! 1 : z ! 1 II3: 1 ! 2 ' 1 ' 2 I
requirementS I .) : I.J J . .J ! 1 1. : \ 2' 1 Minimum staffng 1 2 I 1 I 3 111Iz 113:311;2,2.2:113 Patient complaims 2111112 31112!213111211131313 213 2!212:2;2:2i3\111! 1!113!1 1: 1 ' 11
3\212!31312:312 Infection control procedures 3 I 3 I 3 3! 112 1 Z : 311 ' 2 11 1 2 1 3 I 3 11 3 I 3 I 2 I 3 3 I 2 3111111 31313 3i3: 112;2! 112:z 3' 1: 3 
trained personnel
! 1
Emergency equipmenr and  11312131z13 Medical ,tandards 31212131313 2 \ 2 Z I 3
1213:211 3 I 2 2 I 2 2!21313!3131213121113! 2 3 I 1 2: I' 11 Legallimiu 3121212\212121311 31213131312 3 I 2 2 I 3 2!2121313131213121113: 3!2! 3 I 2 11 2 I 2 li2\I K I L IM:M RAOTEC YAEDIA I N I N L K L N A 5 R A I CD N 5 T EV HY C DJ MH K IWIW'WIW N X T T A AiVllA AA C M N N N N N 0 o UCESURE STATE STATES STATE STATE STANDARS FOR
 HETH FACI UCESUR AGENCI STANARS FOR UCESUR  ! ' FACI 
HETH 
LICENSUR AGENCI STANARS FOR LICENSUR 
STANARS 
FOR 
UCENSUR 
STATE 
Legal limits 

Medical standards 
Emergency equipment and 
trained personnel 
Infection control procedures 
Patient complaints 
Minimum staffng 
requirements 
Peer review 
Transfer agreements 
Equipment standards 
Anesthesia administered by 
qualified personnel 
Record-keeping standards 
Training/certification for

ancilary personnel 
Require facilty to have a 
credentialing process 
Licensure renewal 
The licensure standards listed above relate to outpatient facilties where surgery 
performed. 
We have included only one set of licensure standards for each State. For 41 of the 
States, we used Ambulatory Surgical Center licensure standards. For Idaho and North 
Dakota, we used Home Health Care Agency standards. For Iowa, Washington, West
Virginia, and Wyoming, we used Birthing Center standards. For Maryland and Ohio
we used HMO standards. No standards apply for Vermont or Wisconsin. 
Explanation of rankings (1, 2, or 3) is on pages D- , D- , and D
D - 3  FACI 
HETH 
liCENSUR AGENCI STANARS FOR liCENSUR 
STANARS 
FOR 
LICENSUR  STATE 
Legal limits 

Medical standards 
Emergency equipment and 
trained personnel 
Infection control procedures 
Patient complaints 
Minimum staffng 
requirements 
Peer review

Transfer agreements 
Equipment standards 
Anesthesia administered by 
qualified personnel 
Record-keeping standards 
Training/certifcation for 
ancilary personnel 
Require facilty to have a 
credentiaIing process 
Licensure renewal 
The licensure standards listed above relate to outpatient facilties where surgery 
performed. 
We have included only one set of licensure standards for each State. For 41 of the 
States, we used Ambulatory Surgical Center licensure standards. For Idaho and 
North 
Dakota, we used Home Health Care Agency standards. For Iowa, Washington, West
Virginia, and Wyoming, we used Birthing Center standards. For Maryland and Ohio
we used HMO standards. No standards apply for Vermont or Wisconsin. 
Explanation of rankings (1, 2, or 3) is on pages D- , D- , and D
D - 4  FACi 
HETH  LICENSUR AGENCI STANARS FOR liCESUR 
STANARS FOR 
liCENSUR  STATE 
Legal limits 

Medical standards 
Emergency equipment and 
trained personnel 
Infection control procedures 
Patient complaints 
Minimum staffng 
requirements 
Peer review

Transfer agreements 
Equipment standards 
Anesthesia administered by 
qualified personnel 
Record-keeping standards 
Training/certification for

ancilary personnel 
Require facilty to have a 
credentialing process 
Licensure renewal 
The licensure standards listed above relate to outpatient facilties where surgery 
performed. 
We have included only one set of licensure standards for each State. For 41 of the 
States, we used Ambulatory Surgical Center licensure standards. For Idaho and North 
Dakota, we used Home Health Care Agency standards. For Iowa, Washigton, West 
Virginia, and Wyoming, we used Birthing Center standards. 
For Maryland and Ohio 
we used HMO standards. No standards apply for Vermont or Wisconsin. 
Explanation of rankings (1, 2, or 3) is on pages D- , D- , and D
D - 5  HETH FACIIT UCENSUR AGENCI STANARS FOR UCESUR 
STANARS 
FOR 
LICENSUR  STATE 
Legal limits 
Medical standards 
Emergency equipment and 
trained personnel 
Infection control procedures 
Patient complaints 
Minimum staffng 
requirements 
Peer review

Transfer agreements 
Equipment standards 
Anesthesia administered by 
qualified personnel 
Record-keeping standards 
Training/certification for

ancilary personnel 
Require facilty to have a 
credentialing process 
Licensure renewal 
The licensure standards listed above relate to outpatient facilties where 
surgery is 
performed. 
We have included only one set of licensure standards for each State. For 41 of the 
States, we used Ambulatory Surgical Center licensure standards. For Idaho and North 
Dakota, we used Home Health Care Agency standards. For Iowa, Washington, West 
Virginia, and Wyoming, we used Birthing Center standards. For 
Maryland and Ohio
we used HMO standards. No standards apply for Vermont or Wisconsin. 
Exlanation of rankings (1, 2, or 3) is on pages D- , D- , and D
D - 6  FACI 
HETH  LICENSUR AGENCIE STANARS FOR UCENSUR 
Legal limits 

1 - No standards apply or the information received was incomplete. 
2 - Guidelines for patient care, such as tye of anesthesia allowed or length of stay, 
are listed as requirements for licensure. 
3 - In addition to the guidelines listed above, the governing body of each licensed 
facilty is required to establish a list of procedures that can be legally performed 
in that setting.

Medical standards

1 - No standards apply or the information received was incomplete.

2 - The health facility licensure agency requires that surgical procedures be 
performed by physicians who are licensed in 
that State. 
3 - The health facility licensure agency requires that surgical procedures be 
performed by physicians who are licensed in that State and requires that 
physicians be granted privileges to perform those procedures by the facilty. 
Emergency equipment and trained personnel 
1 - No standards apply or the information received was incomplete. 
2 - Licensure standards address the presence of emergency equipment or the 
presence of personnel trained in emergency procedures. 
3 - Licensure standards address the presence of emergency equipment and 
presence of personnel trained in emergency procedures in great detail. 
Infection control procedures

1 - No standards apply or the information received was incomplete.

2 - Licensure standards for infection control procedures exist but are 
not explained 
in great detail. 
3 - Licensure standards for infection control procedures are explicit and may 
include designated committees that provide oversight in this area. 
Patient complaints 
1 - No standards apply or the information received was incomplete. 
2 - The health facilty 
licensure agency requires the facilty to have a process in 
place to receive patient complaints but does not go into great detail. 
3 - The health facility licensure agency requires the facility to have a specific 
process in place to receive patient complaints.

D 
 Minimum staffing requirements 
1 - No standards apply or the information received was incomplete. 
2 - The health facilty licensure agency requires the facility to have established a 
minimum staff requirement for qualified personnel to be onsite during the 
hours of operation. 
3 - The health facilty licensure agency requires the facilty to have established a 
minimum staff requirement for qualified personnel and a 
physician or a 
registered nurse to be onsite during the hours of operation. 
Peer review

1 - No standards apply or the information received was incomplete. 
2 - Licensure standards require the facility to have some form of internal peer 
reVIew. 
3 - Licensure standards require the facilty to have some form of internal peer 
review within specified time frames. 
Transfer agreements

1 - No standards apply or the information received was incomplete.

2 - The health facilty licensure agency requires that the facility have a wrtten 
patient transfer agreement with a hospital that is located nearby. 
3 - The health facility licensure agency requires that the facility have a wrtten 
patient transfer agreement with a hospital that is located nearby; or it requires 
the physicians from that facilty to have admitting/staff 
privileges at a local 
hospital. 
Equipment standards

1 - No standards apply or the information received was incomplete.

2 - Licensure standards require that all equipment be inspected, maintained, and 
calibrated. 
3 - Licensure standards require that all equipment be inspected, maintained, and 
calibrated within specified time frames. 
Anesthesia administered by qualified personnel

1 - No standards apply or the information received was incomplete.

2 - Licensure standards require that anesthesia be administered by qualified 
personnel. 
3 - Licensure standards require that anesthesia be administered by qualified 
personnel with specific provisions in place for the administration of a general 
anesthetic. 
Record-keeping standards 
1 - No standards apply or the information received was incomplete. 
2 - Licensure standards require the facility to have patient records which contain 
personal and medical information for each patient. 
3 - Licensure standards require the facilty to have patient records which contain 
personal and medical information and a post-operative report for each patient. 
D - 8
 * = 
Training/certifcation for ancilary personnel

1 - No standards apply or the information received was incomplete.

2 - The health facility licensure agency requires that the ancilary personnel 
employed in the facility are qualified for their position through previous training 
or certification. 
3 - The health facility licensure agency requires that the ancilary personnel 
employed in the facilty are qualified for their position through previous training 
or certification. These employees must also be CPR certified and take part in 
continuing education courses. 
Require facilty to have a credentialing process

1 - No standards apply or the information received was incomplete.

2 - The health facilty licensure agency requires the facilty to have a credentialing 
process in place to review the credentials of potential professional staff but 
does not specify whose role this is or the credentialing process. 
3 - The health facility licensure agency requires the facility to have a credentialing 
process in place to review the credentials of potential professional staff. The 
accrediting body specifies whose role this is and lists the criteria used in the 
credentialing process. 
Licensure renewal
1 = 
Annual renewal
2 = 
Biennial renewal 
Renewal periods vary depending on the tye of facilty that is being licensed 
D - 9
 APPENDIX E

STATE MEDICAL AN OSTEOPATHC BOARS 
STANARS FOR LICENSUR

E -
 1'edicinc did nUt respnnd. st:c O:ueup:l1hic Bunn.I uf . The Tcnnc (hou :Ipply. A blank imJicDlcs Ihe Simc h:ls nOI responded or :hcrc arc nu SI:1m..I:WJs :.mJ E. s (1. !. IJr J) is un p3 pl:Jn:Jliun uf r:nkin  SI -Ostcop:llhic board STATE "" Medic:'1 buardTII: 2!2 rc:nt:wul flicensure ' Jj 3 J '.; :: :: :: .2 J i J :J J' J :: .2 :: ,;alicni complainl5 ! P.2 I I .2 Z l 2 Infection caMlrol procedures ; I I I 2,.2!.212 2:1 ::2 i Emergency procedures 12:2, J Mcdic4:1 standards 2::: Jfl!1 2
' L Z I I legal Jimils I l IJ j JIJ .2 licensure Minimum siandan.ls for  ;J. IGIH C L 0 T E:L-R A K;Z LICENSURE I":A'" A A"C C C C D D F STIIDIIRDS FOR  ,; ) 
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osmor/Il IIC nOARDS
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;: 2 J1 2 I::: J 1 l I I I -:! I.:: I ' 2 :! I I I: ! 2 J J J J 3 J ! 3 J  T T II )1i A A V  T U V V W W W W- W w -..-:: :: :: STATE MEDICAL AN OSTEOPATHC BOARS 
STANARS FOR LICENSUR 
STANARS FOR

LICENSUR

Minimum standards for

licensure

Legal limits 

Medical standards

Emergency procedures

Infection control procedures

Patient complaints 
Licensure renewal 
STATE = Medical board 
STATE = Osteopathic board 
Explanation of rankings (1, 2, or 3) is on pages E-8 and E
A blank indicates the State has not responded or there are no standards that apply. 
E - 3
 STATE MEDICAL AN OSTEOPATIC BOARS 
STANARS FOR LICENSUR 
STANARS FOR

LICENSUR

Minimum standards for

licensure

Legal limits 
Medical standards

Emergency procedures

Infection control procedures

Patient complaints 
Licensure renewal 
STATE = Medical board 
STATE = Osteopathic board 
Explanation of rankings (1, 2, or 3) is on pages E-8 and E
A blank indicates the State has not responded or there are no standards that apply. 
E - 4
 AN 
STATE MEDICAL  OSTEOPATHC BOARS 
STANARS FOR LICENSUR 
STANARS 
FOR

LICENSUR

Minimum standards for

licensure

Legal limits 

Medical standards

Emergency procedures

Infection control procedures

Patient complaints 
Licensure renewal 
STATE = Medical board 
STATE = Osteopathic board 
Explanation of rankings (1, 2, or 3) is on pages E-8 and E
A blank indicates the State has not responded or there are no standards that apply. 
E - 5
 STATE MEDICAL AN OSTEOPATHC BOARS 
STANARS FOR LICENSUR 
STANARS FOR

LICENSUR

Minimum standards for

licensure

Legal limits 

Medical standards

Emergency procedures

Infection control procedures

Patient complaints 
Licensure renewal 
STATE = Medical board 
STATE = Osteopathic board 
Explanation of rankings (1, 2, or 3) is on pages E-8 and E
A blank indicates the State has not responded or there are no standards that apply. 
E - 6
 STATE MEDICAL AN OSTEOPATHC BOARS 
STANARS FOR LICENSUR 
STANARS FOR

LICENSUR

Minimum standards for

licensure

Legal limits 
Medical standards

Emergency procedures

Infection control procedures

Patient complaints 
Licensure renewal 
STATE = Medical board 
STATE = Osteopathic board 
Explanation of rankings (1, 2, or 3) is on pages E-8 and E
A blank indicates the State has not responded or there are no standards that apply. 
* The Tennessee Osteopathic Board of Medicine did not respond. 
E - 7
 AN 
STATE MEDICAL  OSTEOPATHC BOARS 
STANARS FOR LICESUR 
Minimum standards for licensure 
1 - No standards apply or the information received was incomplete. 
2 - Candidates for licensure must be graduates of an approved or accredited 
medical or osteopathic school, must have passed National Boards (or 
equivalent), and must have passed State licensure exam. 
3 - Candidates for licensure must be graduates of an approved or accredited 
medical or osteopathic school, must have passed National Boards (or 
equivalent), must have passed State licensure exam, and must have completed 
at least one year of postgraduate training (internship, 
residency, or equivalent). 
Legal limits 

1 - No standards apply or the information received was incomplete. 
2 - Licensed practitioners are required to adhere to at least minimal "standards of 
care" that have been established. 
3 - Licensed practitioners are prohibited from performing certain specific 
procedures that do not adhere to minimal "standards of care. 
Medical standards

1 - No standards apply or the information received was incomplete.

2 -
Education and medical standards (including continuing medical education) is 
referenced in the State s rules and regulations. 
3 - Specific subjects and courses of study that are required for licensure are listed 
in the State s rules and regulations. 
Emergency procedures 
1 - No standards apply or the information received was incomplete. 
2 - Knowledge of emergency procedures (such as CPR) is considered to be part of 
the education, training, or examination process. The Board considers it to be 
an indirect requirement for licensure. 
3 - Knowledge of emergency procedures is a direct requirement 
for licensure. 
Infection control procedures 
1 - No standards apply or the information received was incomplete. 
2 - Knowledge of infection control procedures is considered to be 
part of the 
education, training, or examination process. The Board considers it to be an 
indirect requirement for licensure. 
3 - Knowledge of infection control procedures is a direct requirement for licensure. 
E - 8
 Patient complaints

1 - No standards apply or the information received was incomplete.

2 - Members of the Board receive and investigate patient complaints.

3 - There is a specific unit or office within the Board that is designed solely to

receive and investigate patient complaints. 
Licensure renewal 
1 - Licenses are renewed annually. 
2 -
Licenses are renewed biennially. 
3 - Licenses are renewed triennially. 
E - 9
 APPENDIX 

STATE PODIATRY BOARS STANARS FOR LICENSUR

F - 1
 re",'ision. place prior to chis t:re ine for Dc:lilU':Jre represenl the rules :md regulations that \\'smnd:::ds listed aho\'e;)r. The licensurethe: end of Februal! of thisre\'ised and wil go into elTect lit bt:enhOl\' thoU Ihdr rules ami n:(!ul:uinm; . The Strite of Delaware has imlic:ned  A blank indicates the State has not respunded or thc:re are no sl:ndmus Ihal apply.  am.! Fnkings (I. 2. or 3) is on pagc:s - r Explam:uion  Podiatry board STATE  1: 1 2 I 1 i 1 1 . , 2 . : Licensure renewal 1 3 3 3 I :! 2 3 2 : 3 ' 3 Patient complaints 1 : 2 : 2 2 i I 1 ; 2 J 3 2 ' 2 I 2 ; 2 rocc:uures Infection comrol p1 ! 2 ! 2 1: 1 ; I 2 ; 2 2 f 2 Emergency procedure, 1 I 2 ; 3 , 2 ' 1 ; 3 : Medical sumdards i L 2:3 3 3 2 . 3 gal limits :2 2 2 I 3 3 : 3 3 ' 2 ' 3 I 2 r 3 licensure : Minimum st::mdards for : i D:L:N:A A ES YL K ZiR;A O T EC L j LICESUR I: I - K; L MG H i STANDARDS FORI: I: A:A!C!C C D D F-iA A  STATE PODI ! ., ' . .,:! :? - , - ! - ,
  A
2 2 DM TR
1 2 I !:3:2;23 1:3i2j2  2. l ' 2 . l : 1 ! 2 ; 1 ; 2 : 1li2!1I!I_ 2'1:2 2!li2 2 2'3: 2 3 3.2 212  T E S O A-M M M:N  M:M.M  STANDARS FOR LICY BOARDS  : , 
! 1:3 1:) !2!3 1:2:3 IIi 2 I; 2 ! !liI 2:2  1!2 2:211:313 3 2!23:3 Y C, HINi NjO ENSURE  " ., '

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        STATE PODIATRY BOARS STANARS FOR LICENSUR

STANARS FOR

LICENSUR

Minimum standards for 
licensure 
Legal limits 

Medical standards 
Emergency procedures 
Infection control procedures 
Patient complaints 
Licensure renewal 
STATE = Podiatry board 
Explanation of rankings (1, 2, or 3) is on pages F-7 and F
A blank indicates the State has not responded or there are no standards that apply. 
* The State of Delaware has indicated that their rules and regulations have been 
revised and will go into effect at the end of February of this year. The licensure 
standards listed above for Delaware represent the rules and regulations that were in 
place prior to this revision. 
F - 3
 STATE PODIAlRY BOARS STANARS FOR LICENSUR 
STANARS 
FOR

LICENSUR

Minimum standards for

licensure

Legal limits 

Medical standards

Emergency procedures

Infection control procedures

Patient complaints 
Licensure renewal 
STATE = Podiatry board 
Explanation of ran kings (1, 2, or 3) is on pages F-7 and F
A blank indicates the State has not responded or there are no standards that apply. 
F - 4
 STATE PODIATRY BOARS STANARS FOR LICENSUR

STANARS 
FOR

LICENSUR

Minimum standards for

licensure

Legal limits 
Medical standards

Emergency procedures

Infection control procedures

Patient complaints

Licensure renewal

STATE = Podiatry board 
Explanation of ran kings (1, 2, or 3) is on pages F-7 and F
A blank indicates the State has not responded or there are no standards that 
apply. 
F - 5
 STATE PODIATRY BOARS STANARS FOR LICENSUR

STANARS FOR

LICENSUR

Minimum standards for

licensure

Legal limits 

Medical standards

Emergency procedures

Infection control procedures

Patient complaints

Licensure renewal 
STATE = Podiatry board 
Explanation of rankings (1, 2, or 3) is on pages F-7 and F
A blank indicates the State has not responded or there are no standards that apply. 
F - 6
 STATE PODIAlRY BOARS STANARS FOR LICENSUR 
Minimum standards for licensure

1 - No standards apply or the information received was incomplete.

2 - Candidates for licensure must be graduates of an approved or accredited 
podiatry school, must have passed National Boards (or equivalent), and must 
have passed State licensure exam. 
3 - Candidates for licensure must be graduates of an approved or accredited 
, must have passed National Boards (or equivalent), must have 
podiatry school
passed State licensure exam, and must have completed at least one year of 
postgraduate training (internship, preceptorship, or equivalent). 
Legal limits

1 - No standards apply or the information received was incomplete.

2 - Licensed practitioners are required to adhere to written 
guidelines for the parts 
of the human foot that a podiatrist can treat. 
3 - Licensed practitioners are restricted from performing amputations and/or are 
prohibited from administering anesthetics other than local anesthetic. 
Medical standards

1 - No standards apply or the information received was incomplete.

2 - Education and medical standards (including continuing medical education) is 
referenced in the State s rules and regulations. 
3 - Specific subjects and courses of study that are required for licensure are listed 
in the State s rules and regulations. 
Emergency procedures 
1 - No standards apply or the information received was incomplete. 
2 -
Knowledge of emergency procedures (such as CPR) is considered to be part of 
the education, training, or examination process. The Board considers it to be 
an indirect requirement for licensure. 
3 - Knowledge of emergency procedures is a direct requirement 
for licensure. 
Infection control procedures 
1 - No standards apply or the information received was incomplete. 
2 - Knowledge of infection control procedures is considered to be part 
of the 
education, training, or examination process. The Board considers it to be an 
indirect requirement for licensure. 
3 - Knowledge of infection control procedures is a direct requirement for licensure. 
Patient complaints

1 - No standards apply or the information received was incomplete.

2 - Members of the Board receive and investigate patient complaints. 
3 - There is a specific unit or office within the Board that is designed solely to 
receive and investigate patient complaints. 
F - 7  Licensure renewal 
1 - Licenses are renewed annually. 
2 -
Licenses are renewed biennially. 
3 - Licenses are renewed triennially. 
F - 8
 APPENDIX G

ACCRDITATION ASOCTION STANARS 
STANARS  AAC  AAF 
JCAHO 
Legal limits 
Medical standards

Emergency equipment and trained personnel

Infection control procedures

Patient complaints 
Minimum staffng requirements 
Peer review

Transfer agreements

Equipment standards

Anesthesia administered by qualified personnel

Record-keeping standards

Training/certifcation for ancilary personnel

Require facility to have a credentialing process

Accreditation renewal

AAC 
- Accreditation Association for Ambulatory Health Care 
AASF - Accreditation Association for Podiatric Surgical Facilities 
JCAHO - Joint Commission on the Accreditation of Healthcare Organizations 
Legal limits 
1 - No standards apply or the information received was incomplete. 
2 - Procedures that can be performed are established by the facility or the 
physician s practice and are examined 
as part of the accreditation process. 
3 - The accreditation association establishes their own list of procedures that can 
be performed in each setting. 
G - 1
 Medical standards 
1 - No standards apply or the information received was incomplete. 
2 - The accreditation association requires that surgical procedures be performed by 
physicians who are licensed in that State. 
3 - The accreditation association requires that surgical procedures be performed by 
physicians who are licensed in that State and physicians must have been 
granted privileges to perform those procedures by the facilty. 
Emergency equipment and trained personnel

1 - No standards apply or the information received was incomplete.

2 - Accreditation standards address the presence of emergency equipment or the 
presence of personnel trained in emergency procedures. 
3 - Accreditation standards address the presence of emergency equipment and 
presence of personnel trained in emergency procedures in great detail. 
Infection control procedures

1 - No standards apply or the information received was incomplete.

2 -
Accreditation standards for infection control procedures exist but are not 
explained in great detail. 
3 - Accreditation standards for infection control procedures are explicit. 
Patient complaints

1 - No standards apply or the information received was incomplete.

2 - The accreditation association requires the facilty to have a process in place to 
receive patient complaints but does not go into great detail. 
3 - The accreditation association requires the facilty to have a specific process in 
place to receive patient complaints.

Minimum staffing requirements 
1 - No standards apply or the information received was incomplete. 
2 - The accreditation association requires the facilty to have established a 
minimum staff requirement for qualified personnel to be onsite during the 
hours of operation. 
3 - The accreditation association requires the facilty to have established a 
minimum staff requirement for qualified personnel and a physician or an 
anesthesiologist to be onsite during the hours of operation. 
Peer review

1 - No standards apply or the information received was incomplete. 
2 - Accreditation standards require the facility to have some form of internal peer 
review for quality assurance. 
3 - Accreditation standards require the facilty to have some form of internal peer 
review with specific time frames mentioned. 
G - 2
 Transfer agreements 
1 - No standards apply or the information received was incomplete. 
2 - The accreditation association requires that the facilty have a wrtten patient 
transfer agreement with a hospital that is located nearby. 
3 - The accreditation association requires that the facility have a wrtten patient 
transfer agreement with a hospital that is located nearby or it requires the 
physicians from that facility to have admitting/staff privileges at a local hospital. 
Equipment standards

1 - No standards apply or the information received was incomplete.

2 - Accreditation standards require that all equipment be inspected, maintained 
and calibrated. 
3 - Accreditation standards require that all equipment be inspected, maintained 
and calibrated within specified time frames. 
Anesthesia administered bv qualified personnel

1 - No standards apply or the information received was incomplete.

2 - Accreditation standards require that anesthesia be administered by qualified 
personnel. 
3 - Accreditation standards require that anesthesia be administered by qualified 
personnel with specific provisions in place for the administration 
of a general 
anesthetic. 
Record-keeping standards

1 - No standards apply or the information received was incomplete.

2 - Accreditation standards require the facility to have patient records which 
contain personal and medical information for each patient. 
3 - Accreditation standards require the facility to have patient records which 
contain personal and medical information and a post-operative report for each 
patient. 
Training/certification for ancilarY personne

1 - No standards apply or the information received was incomplete. 

2 - The accreditation association requires that the ancilary personnel employed in 
the facility are qualified for their position through previous training or 
certification. 
3 - The accreditation association requires that the ancilary personnel employed in 
the facility are qualified for their position through previous training or 
certifcation, that these employees are CPR certified, and that these employees 
take part in continuing education courses. 
G- 3
 Require facility to have a credentialing process 
1 - No standards apply or the information received was incomplete. 
2 - The accreditation association requires the facilty to have 
a credentialing 
process in place to review the credentials of potential professional staff but 
does not specif whose role this is or the criteria involved in the credentialing 
process. 
3 - The accreditation association requires the facility to have a credentialing 
process in place to review the credentials of potential professional staff. The 
accrediting body specifies whose role this is and lists the criteria used in the 
credentialing process.

Accreditation renewal 
AAC 
- An organization can be accredited for three years if it is in substantial 
compliance with the standards. An organization can be accredited for one year if 
it is 
in substantial compliance with the standards but compliance does not appear to be 
well-established or the organization s commitment to one or more of the standards 
appears to be short-lived. Accreditation can be deferred for six months for those 
facilities that have the commitment and the capabilty to correct identified deficiencies 
so that they are in substantial compliance with the standards. Accreditation can also 
be denied to those facilties that are not in substantial compliance with the standards. 
AASF - An organization can be accredited for three years if it is in substantial 
compliance with the standards. An organization can be accredited for less than three 
years if it is in substantial compliance with the standards but compliance does not 
appear to be well-established or the organization s commitment to one or more of the 
standards appears to be short-lived. Accreditation can be deferred for six months for 
those facilities that have the commitment and the capabilty 
to correct identified 
deficiencies so that they are in substantial compliance with the standards. 
Accreditation can also be denied to those facilities that are not in substantial 
compliance with the standards. 
JCAHO - An organization can be accredited for three years if it is in substantial 
compliance with the standards. This award may be accompanied by specific citations 
or Type I recommendations. Organizations with Type I recommendations must 
demonstrate compliance with specified time frames or risk the loss 
of accreditation. 
Organizations not in substantial compliance with standards may become conditionally 
accredited or not accredited. Conditionally accredited organizations must submit a 
Plan of Correction and are subject to a follow-up survey in six months. 
G- 4
 APPENDIX H

ADDmONAL ACCRDITATION ASOCTION STANARS 
Unannuned or uncheduled 
(AAC) 
Accreditation Association for Ambulatory Health Care 
An accredited organization may be re-surveyed with or without advance notice 
AAC. 
at any time at the  No fee shall be charged the 
discretion of the_ 
AAC. 
organization when such a resurvey is initiated at the discretion of the 
AAC 
If an accredited organization is surveyed by the  and is judged not to 
be in substantial compliance with the standards, its accreditation wil be 
revoked. 
Accreditation Association for Podiatric  (AASF) 
Surgical Facilties 
The AASF conducts two tyes of visits. Scheduled visits are always performed 
for initial accreditation and renewal of accreditation. Unscheduled visits are a 
means of following up on facilities that had questionable deficiencies with the 
survey. These facilities are notified of the time period in which another visit 
will be made but the exact date and time of the visit are not given. 
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 
The JCAHO conducts three tyes of visits. Scheduled visits are always 
performed for the initial full survey, renewal full survey, and for focused visits 
(a survey to see that Type 1 recommendations have been resolved). 
Unannounced visits involve a survey team arriving for an inspection without 
facility. This tye of visit is for the more severe
giving prior notification to the 

cases (the level of severity is based upon the perceived threat to patient safety). 
Unscheduled visits are for the less severe cases. These involve giving the 
facility 24 to 48 hours notice prior to the visit. The latter two tyes of visits 
usually take place as a result of information received indicating non-compliance 
patient complaints, or media issues. 
H 
 informtin 
Puli  release of 
(AAC) 
Accreditation Association for Ambulatory Health Care 
AAC 
the  will not release any information obtained through 
the survey 
II Survey findings are released 
without the organization s wrtten authorization. 
AAC 
to the organization only. The general public may call the  offce to 
AAC 
request information on the accreditation status of facilties. The  does 
not provide press releases or wrtten directories. 
Accreditation Association for Podiatric  (AASF) 
Surgical Facilties 
Except as required by law, the AASF will not release any information 
obtained through the survey of an organization without the facilty' s wrtten 
authoriation. Consequently, the contents of the survey report, the survey team 
findings, and the accreditation decision are provided only to the participating 
facility and are disseminated solely at its discretion." There is no directory or 
media release of information. 
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 
The JCAHO does not publish survey findings or accreditation status. A 
facilty s accreditation status and accreditation history are available upon 
request by the public. Survey findings go the Health Care Financing 
Administration and to State agencies if required by law (if the State requires 
accreditation for licensure). 
H- 2