Accreditation is a symbol of the highest form of quality patient care and dedication to patient safety. It can be looked upon as a necessity for your practice and/or facility. However, it can be viewed as a convoluted, difficult process if you are not prepared to deal with it head-on.

Do you have the firm determination to change your attitude and behaviors connected to your plastic surgery center’s accreditation process? If you responded with an enthusiastic and knowing “yes,” time to jumpstart your 2008 New Year’s resolution list.

Currently, accreditation is a voluntary process that enables a medical practice or ambulatory surgery center to measure the quality of its services and performance against nationally recognized standards. The accreditation process involves self-assessment, as well as a thorough review by an accreditation surveyor.

Plastic surgeons may be aware of accreditation but may not realize what is involved in earning it.

It is extremely important, for example, to prepare your facility and ensure that it is compliant in order for you to perform surgical cases using general anesthesia. In addition, your facility should comply with state laws.

Your patients should know that you do comply with the state laws and the standards dictated by the organization you’ve employed to accredit your facility. This shows them the level of quality and credibility your business has attained.

If you are eager to jump on the accreditation bandwagon, it is important to note the two biggest barriers to success: procrastination and unfamiliarity. Eliminate the procrastination by learning more about the accreditation process.

Accreditation is a very lengthy and time-consuming process and is not something you can prepare for in an overnight crunch. It involves a “cultural adaptation” to changes you need to execute. It involves process refinement, job realignment, and forms standardization and/or revision. It involves understanding that you have implemented the best processes.

In order to understand that all possible negative events have been ruled out in your facility processes, you need adequate time to study all processes to be able to support, defend, or eliminate any of them.


Accreditation is a quality seal of approval by an outside agency announcing your level of quality and safety. It is required by most private insurance companies, in order that you can bill and receive payments; and accreditation reduces the potential for adverse outcomes, which in return reduces your liability.

Accreditation announces your practice is adhering to the laws of your state, and it strengthens your place in the marketplace and among consumers.

In order to become eligible for accreditation, you and your facility must abide by certain policies and procedures. Since accrediting agencies have been around for some time, chances are that you or your staff are already somewhat familiar with this process. If not, you must be proactive in your approach to learning about it.

The types of facilities considered for accreditation include ambulatory surgery centers, health care clinics, office-based surgery centers and practices, single specialty group practices, and women’s health centers.

The three nationally recognized accreditation organizations are the Accreditation Association for Ambulatory Health Care, located in Skokie, Ill; The Joint Commission of Oakbrook, Ill; and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) in Gurnee, Ill.

Accreditation is awarded in 6-month, 1-year, and 3-year time cycles. Three-year accreditation awards are earned by facilities that not only comply with an agency’s standards but also provide high quality of care.

If your facility has never been accredited, do not expect to obtain more than a 1-year term. One year is granted based on a surveyor’s recommendations that he or she sees acceptable levels of patient care, as well as sees areas of improvement. In this case, your facility must be resurveyed within 10 months to avoid a lapse in the certification.

Any lapse in accreditation can cause state medical boards to investigate and take formal administrative action against your state license.

A lapse in accreditation brings a work stoppage—your ability to continue to perform surgeries gets put on hold, and continuing to perform surgeries without accreditation puts you, your license, and your facility in grave danger. Your malpractice insurance carrier may be notified of this lack of accreditation; the same goes for state medical boards that would be told of your status via the accrediting agencies’ notification process.

A 6-month term is usually granted to new facilities that are open for business but do not meet certain facility requirements and also have not taken any patients. This short-term, initial accreditation gives the facility a chance to get up to speed and complete the administrative components of its operation.

Armed with an understanding of the terms, you must determine the core standards for your facility when applying for initial accreditation or re-accreditation. Policies and procedures must be developed and in place for the following areas: governance, administration, infection control, risk management, medication management, medical records compliance, HIPAA, OSHA, personnel, anesthesia services, quality assurance, quality improvement, rights of patients, sterilization, and fire and safety.

Although each facility is different, the initial accreditation process can take anywhere from a few months to at least 1 year.

The Business Case for
Embracing Accreditation

  • Provides a seal of approval by an outside agency that declares your practice’s level of quality and safety.
  • Is required by most private insurance companies.
  • Reduces the potential for adverse outcomes, which in return reduces your liability.
  • Declares that your practice complies with state laws.
  • Strengthens your position in the market and among consumers.
  • Promotes you and your facility.

After your application has been submitted and approved, you can expect a surveyor to physically inspect and review your facility within 2 months, provided you’re able to satisfy the accrediting bodies’ prerequisites.

If you are applying for Medicare deemed status, these rules apply. To obtain Medicare, one must meet very strict guidelines of the Life Safety Codes of the NFPA 2000. Depending on the state in which you do business, this process could demand that you answer 180 or so questions, possibly in the presence of the surveyor.

All Medicare certifications—whether issued by an accrediting body via its authority announced by the Centers for Medicare and Medicaid Services and most commonly called deemed status, or Medicare certification issued via the local state department of health services licensure process—require unannounced inspections that will likely take 2 full days of surveyor activity.

It is becoming common that private insurance companies require facilities to be either Medicare-certified or state licensed before they will reimburse your facility fees on submitted claims.


Assuming that you want your facility to be reconfirmed on a regular basis, you should remain aware of the status of your facility and, if possible, meet regularly with the person you have designated to prepare the facility for accreditation. As a result, you should get a sense of your facility’s condition.

The person you designate will have to assume responsibility for completing the myriad accreditation forms—an arduous task.

During the accreditation process, medical directors should ensure a free flow of information and updates from staff.

Throughout this process, seek organizations that provide services that support accreditation. Your medical association should be able to help you find reputable firms.

These companies provide relief for many daunting aspects of the accreditation process. In addition, they can provide consultants to prepare you for accreditation who can assess your facility on-site, prepare compliance checklists, educate the staff on all regulations and quality assurances, and conduct mock surveys and progress evaluations.


Resolve to keep your accreditation materials updated. Accreditation is a continuous process that does not go away once you are awarded certification. Whether you are awarded a term of 3 years, 1 year, or 6 months, you are obligated to continually improve your patient care standards, your facility, your anesthesia policies, and your protocols.

Be prepared to appoint a trustworthy staff member to maintain and manage the process. Ensure that you provide this individual with ongoing guidance and assistance. Consider adopting a quarterly action plan to make sure your facility implements the standards according to your accrediting body.

If you retained a consultant, remain informed and updated on regulatory revisions or changes to the law.

See also “Navigating the Accreditation Maze” by Wendy Lewis in the January 2006 issue of PSP.

Resolve to end the procrastination when it comes to accreditation. Arm yourself with knowledge of the ongoing issues related to new regulatory requirements.

Resolve to place a high value on the prestige of achieving accreditation, and ensure that your entire organization understands the positive aspects of accreditation. Earning accreditation status can be a good way to grow your business.

Finally, resolve to make accreditation readiness an important part of your business goals for sustainable competitive advantage.

Troy Lair, founder and president of The Compliance Doctor, a Los Angeles-based consulting firm, can be reached at (310) 566-7282.