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Understanding Accreditation



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When surgery is performed outside of a hospital setting, it is imperative to make sure the facility of where the procedure is going to be done is accredited.  This will help you make an informed decision on whether or not this procedure should be done in a hospital setting, out-patient surgery center, or free standing ambulatory surgical facility.



1.  Is the facility where my procedure would be performed accredited and in good standing  

     with one of the four accrediting organizations listed below?

2.  Is this where you regularly perform procedures such as the one I am considering?

3.  In the event of an emergency, what is the emergency plan?

4.  What hospital would I be taken to, how far away is it and do you have privileges at that   

     hospital for the procedure you will perform on me?

5.  What is the date of the facility’s most recent accreditation review?






The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)   -   Phone:  888.545.5222





The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)   -   Phone:  630.792.5800






The Accreditation Association for Ambulatory Health Care (AAAHC)   -   Phone:  847.853.6060








The American Osteopathic Association – (AOA)   -   Phone:  800.621.1773





According to the ASAPS, in 2005, a majority of surgical procedures were performed outside of a hospital.  Forty-eight percent (48%) of procedures took place in an office-based facility and twenty eight percent (28%) were performed in a free standing out-patient surgical center.  Research has shown that with proper precautions, surgery outside the hospital setting is just as safe as surgery in a hospital. Additionally, this off site advantage seems to work better for the patient with not only being less costly but also more private and less stress for the patient.

All freestanding outpatient surgical facilities administering sedation of any kind during the performance of any type of surgical procedure must be accredited by one of several approved accrediting bodies rigorous enough to meet the tough standards put out by AB 595. Medicare licensure, accreditation by AAAHC, AAAASF, JCAHO, AOA are the only facility accreditation bodies one should give credence to when evaluating the safety of a facility.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) establishes a baseline standard of excellence among hospitals and is recognized nationwide. You should ask if the hospital where your surgery will be performed is accredited by JCAHO.




‘Patient’s Bill of Rights’

  • The patient has the right to considerate and respectful care.

  • The patient has the right to obtain from his or her physician complete current information concerning his or her diagnosis, treatment and prognosis in terms the patient can be reasonable expected to understand.  When it is not medically advisable to give such information to the patient, the information should be made available to an appropriate person in his or her behalf.  He or she has the right to know, by name, the physician responsible for coordinating his or her care.

  • The patient has the right to receive from his or her physician information necessary to give informed consent prior to the start of any procedure and or treatment.  Except in emergencies, such information for informed consent should include but not necessarily be limited to the specific procedure and or treatment, the medically significant risks involved, and the probable duration of incapacitation.  Where medically significant alternatives for care of treatment exist, or when the patient requests information concerning medical alternative, the patient has the right to know the name of the person responsible for the procedures and or treatment.

  • The patient has the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of his or her action.

  • The patient has the right to every consideration of his or her privacy concerning his or her medical care program.  Case discussions, consultation, examination, and treatment are confidential and should be conducted discreetly.  Those not directly involved in his or her care must have permission of the patient to be present.

  • The patient has the right to expect that all communications and records pertaining to his or her care should be treated as confidential.

  • The patient has the right to expect that within its capacity, the accredited ambulatory surgery facility must provide evaluation, service and or referral as indicated by the urgency of the case.  When medically permissible, a patient may be transferred to another facility only after he or she has received complete information and explanation concerning the needs for the alternatives to such a transfer.  The institution to which the patient is to be transferred must first have accepted the patient for transfer.

  • The patient has the right to obtain information as to any relationship of the facility to other health care and educational institutions insofar as his or her care is concerned.  The patient has the right to obtain information as to the existence of any professional relationships among individuals, by name, who are treating him or her.

  • The patient has the right to be advised if the accredited ambulatory surgery facility proposes to engage in or perform human experimentation affecting his or her care or treatment.  The patient has the right to refuse to participate in such research projects.

  • The patient has the right to expect reasonable continuity of care.  He or she has the right to know in advance what appointment times and physicians are available and where.  The patient has the right to expect that the facility will provide a mechanism whereby he or she is informed by his physician of the patient's continuing health care requirements following discharge.

  • The patient has the right to examine and receive an explanation of his or her bill regardless of the source of payment.

  • The patient has the right to know what facility rules and regulations apply to his or her conduct as a patient.

No catalog of rights can guarantee for the patient the kind of treatment he or she has a right to expect.  The facility has many functions to perform, including the prevention and treatment of disease, the education of both health professionals and patients, and the conduct of clinical research.  All these activities must be conducted with an overriding concern for the patient, and above all, the recognition of his or her dignity as a human being.  Success in achieving this recognition assures success in the defense of the rights of the patient.



It is the patient's responsibility to fully participate in decisions involving his or her own health care and to accept the consequences of these decisions if complications occur.

The patient is expected to follow up on his or her doctor's instructions, take medication when prescribed, and ask questions concerning his or her own health care that he or she feels is necessary.





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