/

,

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. 

OFFICE OF EVALUATION AN 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 
Department of Health and Human 
 Servces 

OFFICE OF


INSPECTOR GENERAL


SURGERY IN OUTPATIENT SETTINGS:


FORMS OF OVERSIGHT


.. SERVIC'~o to" 

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.


ACCREDITATION, CERTIICATION, AN 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. 

mERE IS LIE 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1989 Part B Medicare Annual Data (BMA) selected procedures 

and number of procedures performed in each setting . . . . . . . . . . . . . . . . .. BTypes of facilities and the number of State health facilty licensure 

agencies that license each. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. CState health facility licensure agencies standards for licensure . . . . . . . . . . . . DState medical and osteopathic boards standards for licensure . . . . . . . . . . .. EState podiatry boards standards for licensure . . . . . . . . . . . . . . . . . . . . . . .. FAccreditation association standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GAdditional 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 highrisk 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. 

No Uniform Defitin of Surer 

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. 

Overv of Outit Faci 

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. 

Type of Faci and Exmple of Predes 

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 

of facilties. If a facilty chooses not to seek certification, physicians can stil 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 officebased 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 

malpractice/liabilty insurance for individual physicians and/or facilities. We contacted 

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 

place at day surgery centers, and claim information. There are 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 

Accreditation Association for Ambulatory Health Care (AAC), 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. 

1. Patit Complaints - The State health facilty licensure agency requires the 

facilty to have a system to receive patient complaints in: 

31 of the 51 States. 

2. Leal Limits - Guidelines for care (including surgical procedures) in an 

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. 

3. Peer Rev - The State health facilty licensure agency requires the facility 

to have some form of peer review as part of the internal quality assurance 

program in: 

34 of the 51 States. 

4. Training for Anry Personnl - The State health facilty licensure agency 

requires training and/or certification of ancilary personnel (i.e. lab technicians 

or nurses aides) in: 

41 of the 51 States. 

5. Credtiling Proces - The State health facility licensure agency requires 

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. 
Infectin Contrl Predes - The State licensure authorities require that 

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 

6. 

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 

written patient transfer agreement between the outpatient surgical facility and a 

hospital in: 

8. 

43 of the 51 States. 

9. Minim Staff Reqemt - The State health facility licensure agency 

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. 

11. Minim Record-Keeping Standrds - The State health facility licensure 

agency requires the outpatient surgical facilty to have minimum record-keeping 

standards in: 

47 of the 51 States. 

12. Anethe Standrd - The State health facility licensure agency requires 

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. 

13. Eqipmet Standrds - The State health licensure agency requires regular 

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 tyes of procedures in outpatient 

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 the Thee accreditation associations that we contacted had a definition 

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. " 

On insurance company s definition of surgery is: 

- 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." 

None of the professional organizations that we contacted had a definition of surgery. 

AU of the PROs that we contacted had a definition of surgery. 

Surgery - (a.) that discipline of health care delivery utilizing the knife, cautery, 

cryogenics, or chemicals, (b.) invasive procedures to remove, correct, or 

faciltate the cure of a disease, process, or injury, and (c.) that branch of 

medicine which treats diseases methods." , 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. 

Seven of the 
 51 State health licensure agencies that we contacted had a 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 

including a closed as well as an Qpen reduction of a fracture; extraction of 

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. 

Four of the 63 State medical and osteopathic boards that we contacted had a definition 

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... 

Six of the 50 State podiatry boards that we contacted had a definition for surgery. 

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

TYES OF FAOU AND TIlE NUMER OF STATE HEATH FACl UCESU AGENCI THT UCESE EACH 

TYES OF FACl 

Ambulatory SurgiOinic Ambulntory Henlth Cnre 

cal Conter 

Cancer 

Center 

Urgent/Immediate C:uc


Orgnniwtion He:llt'" Maintenance Birthing Center 

Tre:ltm nt Cc:ntcr 

Emergency 

Cardiac C::thetenZ3tion Lab 

nter 

Independent CliHome Health Care Agency 

nical Lab 

Diagnostic rmaging Ce

Abortion Clinic 

nter 

Offce Surgery Center 

Physici Offce 

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 

tye of 

given State and the reader should refer to the enclosed indicmes there are conditions thnt relate to licensure of this fj-pe of facilry in a facility does noc exist in the State 

(oOtnotes for gre:uer 

indicates the licensure 

detnil 

lus of many or 311of the facilities in a given St:1tc :'re 

unclenr nnd the reader should refer to the enclosed foolDotes for grea.er demil 
TYES OF FACI AN TH NUER OF STATE HETH FACI


LICENSUR AGENCIE THT UCENSE EACH 

TYES OF FACIIT 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

TYES OF FACl AN TH NUER OF STAll HETH FACI 

LICENSUR AGENCI THT UCENSE EACH 

TYES OF FACl 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

TYES OF FACI AN TH NUER OF STATE HETH FACl


LICENSUR AGENCIE THT LICENSE EACH 

TYES OF FACIIT 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

TYES OF FACI AN TH NUER OF STATE HETH FACIIT


UCENSUR AGENCI mAT LICENSE EACH 

TYES OF FACI 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 OF STATE RETI FACI 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. 

Oklahoma - Legislation on licensure of Birthing Centers is pending. Laboratories State). that test for the presence of HN are licensed (there are less than 20 of these in the

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


STATE HETH FACILIT LICENSUR AGENCIE 

STANARS FOR LICENSUR 

D -

HETH FACI UCESUR AGENCI STANARS FOR UCESUR 

UCESURE 

STANDARS FOR


STATES STATE STATE STATE 

A A A C M N N N N N 0 o 

T E V H J M Y C D H K R A I CD N X T T A AiVll L K RAOTEC L N A 5 YAEDIA N 5 I N I N IWIW'WIW 

3121212\212121311 3 I 2 31213131312 2 I 3 2 I 2 3 I 2 11 2!2121313131213121113: 3!2! li2\ I K I L IM:M Legallimiu 

2 I 2 3 I 2 3 I 1 2!21313!3131213121113! 2 2: I' 11 Medical ,tandards 11312131z13 1213:211 2 \ 2 31212131313 Z I 3


Emergency equipmenr and ! 1


Infection control procedures 

trained personnel


3 I 3 I 3 3\212!31312:312 3! 112 3 I 3 I 2 I 3 1 Z : 311 ' 2 11 1 2 1 3 I 3 11 3 I 2 3111111 31313 3i3: 112;2! 112:z 3' 1: 3 


' 11


Patient complaims I 1 I 3 111Iz 113:311;2,2.2:113 2111112 213 31112!213111211131313 1!113!1 2!212:2;2:2i3\111! 1: 1 Minimum staffng 1. : ! 1 1 2 \ 2 ' 1 requirementS I .) : J . .J I.J 

! 2 ' 1 ' 2 I


Peer review 1213121113111312: 11312:2 ' 1\1131,lz 2!3 212 3 11 I 2 1: 11z121312! 11112 3: 3 I 2 i 2 3: 1 ! 1 : z ! 1 II 3 I 3


0 !


Transfer 3greemenlS 1212121213131313 ' 3 3!3 113!2121 113\2 3!3'21212'2 211121211!21213!2:1!112 3!2 112.


Equipment standard, I 2 I 3 21212121312! zl3 :2 '2; 1 IZ\Z:2: 212;3; 3 2IzI2:2!31113121212 2IzI3IzII12 21212: 2:2;Z:2; 111 2: 1


Anesthesii: administered by i 3 ! 2 qualifed personnel ! 3 1 3 ! 3 ! 2 ! 1 1 3 ! 2 ! 1 !2 ! 2 1 I ! 2 

Record-keeping standards 13:31313!3! 3 i 3! 3! 3; 313 3;1\3131313 313:313;3!3\313 31312131312 3131112:2 3IzI3 3iJ lr3: ' 1 : 3 I 

Trnininglcc:rtifcation for ! 3 ! z 1 2 1 3 ancilary personnel 1 z ll 12 1 1 

Require facilty to have I I 3:3;2, 1 3 111
 credemialing process ! 3 13 11 12


licensure ren wal II 11 1 11 11 11 1 2 11 ! 1 I 2 i I ! Z ! 1 1111111 1 i 1 : I! 3 : 2 ! 1 11 ! 1 11 11 I, '111111 2 I' I I 11 11 I 1 11 II : 1 " 1 : 1 i , : 1 I 1 I 1 - I ! 1 ; 1 ' 1 I 

The lice sure smndards listed above relate: to outpatient facilties where surgery is 

Dakota. we u,ed Home Health Care Agency standard,. For Iowa

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. 

, Washington. West 

E'Planation of ranking' (I, 2, or 3) i, on page' Dwe 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 

, D-8, and D­
HETH FACI 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 DD - 3 
HETH FACI 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 DD - 4 
HETH FACi 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 DD - 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 DD - 6 
HETH FACI 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 -

.__ 

!_ 

! 

! :: 

! 

..

,; ) ) 

) 

) ) ) ) ) 

STAlE MEDIC,IL IID osmor/Il IIC nOARDS


ST,\NDARDS fOR UCfiStJRE


STIIDIIRDS FOR 

I":A'" A A" C C C C D D F P - R S ' S T T T U V V W W W W - W w LICENSURE :L- K;Z R A 0 T E C L ;J. M M1M M;M'M M M' M;N N N N N N N'N_ N:N:01oio' o.r IGIH AiE .6:DA , I S O V )1jH J M M:Y!C R;A !D N - T T II A A V )1i 

licensure Minimum siandan.ls for 

.2 J j JIJ 1:3 j 3. 313 ) 3 3 '3, 3:33- ):3,3 ) 3 3 ) ) 3 J J 3 J ! 3 J J J legal Jimils I l I ' L Z I I 2::: Jfl!l 1 2


J Mcdic4:1 standards 12:2, .2 2. 2:1 1 .2 I;:L I 2 ! l I 1 l : 2 1 2; I I I :: :: l J ! 2 I I: i Emergency procedures 12 2:1 ::2 :: 1 :! I ' J J ;: J:I: l ;:. 2 1 J I :! I.:: I :! I ' 2 

I 2,; I I .2!.2: l 2 .2 .2 t :! :! I I I I I . :: : I I. 1 . t I I I I - I I Infection caMlrol procedures l 2 .2 Z .2 I I 

! Palicni complainl5 2 ) :! 2 I I I I I :: , I I' I , I I :: :: 2 1 2 I::: J 1 l 

flicensure rc:nt:wul TII: .2 2 J J.J J J J .1 .1 J 2 J J J 't .. , I J ) ;: 2 J J J ' J :: .2 :: ,; .; :: :: :: .2 J i J :J 'j 3 ' J J j J J J J 
 't ..
 2!2 ! :! ' )1111-;' ;: 1 I ;: 3 i 2 ' :: I :: ' I I . 1 t I 

SI - STATE "" Medic:'1 buard Ostcop:llhic board 

pl:Jn:Jliun uf r:nkin s (1. !. IJr J) is un p3 :.mJ E. 

A blank imJicDlcs Ihe Simc h:ls nOI responded or :hcrc arc nu SI:1m..I:WJs(hou :Ipply. 

. The Tcnncst:c O:ueup:l1hic Bunn.I uf 1'edicinc did nUt respnnd. 
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 EA 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 EA blank indicates the State has not responded or there are no standards that apply. 

E - 4

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 EA 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 EA 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 EA 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

STATE MEDICAL AN 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

! . . ., 

, 

! 

, :! :? 

. 

.

, 

: , , 

STATE PODIATRY BOARDS STANDARS FOR LICENSURE 

i STANDARDS FOR iA A A:A!C!C C D D F- G H I: I I: I: - K; L M M M:M.M M M M:N NjO j LICESUR L K ZiR;A O T EC L D:L:N:A S Y A E D A- S O T E INi Y C, H K 'RiA CDNXTTAAV : i 

: Minimum st::mdards for 

licensure r 3 3 ' 2 ' 3 I 2 2 I 3 3 : 3 :2 2 3.2 212 3:3, 112, 

i L gal limits 2 . 3 3 3 2:3 2 3 '3: 2:313 3 2!2!2il 2!2 : Medical sumdards 1 ; 3 1 I 2 ; 3 , 2 ' 2 2 2'1:2 2!li2 1!2 2:211:2:1 1!2 

Emergency procedure, 2 f 2 2 ; 2 ; I 1 ! 2 ! 2 1: 1 I!I_ li2!1!liI 2:2 1:l llil 1 1 

Infection comrol procc:uures ; 2 2 ' 2 I 2 J 3 1 ; 2 1 : 2 : 2 2 i I 2 2. l ' 2 . l : 1 ! 2 ; 1 ; 2 : 1 IIi 2 I; 2 ! 1 IIi I : 1 I 2 2 1 

Patient complaints 2 : 3 ' 3 2 3 3 I :! 1 3 3 3 1:3i2j2 3:2;2!2!3 1:2:3 3;1 3i2 3 2 

: Licensure renewal 2 . 1 . , 2 I 1 i 1 1: 1 1 2 I !:! 1:3 1:) 1:2 2:2 2, 1 

STATE Podiatry board Explam:uion - r nkings (I. 2. or 3) is on pagc:s am.! F­

. The Strite of Delaware has imlic:ned 

A blank indicates the State has not respunded or thc:re are no sl:ndmus Ihal apply. 

thoU Ihdr rules ami n:(!ul:uinm; hOl\' bt:en re\'ised and wil go into elTect lit the: end of Februal! of this e;)r. The licensure smnd:::ds listed aho\'e for Dc:lilU':Jre represenl the rules :md regulations that \\'t:re in place prior to chis re",'ision. 
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 FA 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 FA 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 FA 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 FA 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 

podiatry 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, 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 

Accreditation Association for Ambulatory Health Care (AAC) 

An accredited organization may be re-surveyed with or without advance notice 

at any time at the discretion of the_ AAC. No fee shall be charged the 

organization when such a resurvey is initiated at the discretion of the AAC. 

If an accredited organization is surveyed by the AAC and is judged not to 

be in substantial compliance with the standards, its accreditation wil be 

revoked. 

Accreditation Association for Podiatric Surgical Facilties (AASF) 

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 ­

Puli release of informtin 

Accreditation Association for Ambulatory Health Care (AAC) 

the AAC will not release any information obtained through the survey 

without the organization s wrtten authorization. II Survey findings are released 

to the organization only. The general public may call the AAC offce to 

request information on the accreditation status of facilties. The AAC does 

not provide press releases or wrtten directories. 

Accreditation Association for Podiatric Surgical Facilties (AASF) 

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