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Archive April 2018 XIX, No. 4

7 Accreditation Standards You Might Now Know Exist

You might be unaware of some of these common deficiencies I cite as a surveyor.

Kathy Beydler

Kathy Beydler, RN, MBA, CASC, CNOR


SURPRISING DINGS You might be overlooking certain accreditation standards — and not even know it.

When I check in with my husband after completing an accreditation survey, he tries to guess which deficiencies I found. "Was it safe injection practices or the IFUs this time? I bet it was the IFUs." He's not even in health care, but he's repeatedly heard me mention the same 7 standards that administrators and OR managers are almost always surprised to learn they're not following.

1. Disaster prep

If you're seeking CMS accreditation, you need to be aware of these new standards on disaster preparedness. I've performed many CMS surveys since it went into effect in November of last year and found early on that many of you aren't aware of these requirements. Most surgery center leaders are accustomed to thinking that we're not involved with disaster prep, but CMS has changed that. In the event of a large-scale emergency situation, like the mass shooting in Las Vegas, Nev., hospitals might not have the resources or personnel to accommodate a huge influx of patients. So the new standards for CMS accreditation require that your surgery center be prepared if the state or federal government issues a state of emergency and directs patients to your facility. I'll highlight a few here and the rest you can find in a link I've provided to CMS Emergency Preparedness Guidelines and Notes for the Surveyor (

  • You have to be able to shelter in place with patients and staff. This means you must have access to potable water and snacks, and a place for people to stay for extended periods of time if that becomes necessary.
  • You must have a way to track your staff in case they have to go with a patient temporarily to another facility.
  • If your governor or the President issues a waiver for additional healthcare professionals to come help you, you have to be ready to handle them.
  • You have to coordinate with your local emergency management association to let them know what resources you have at your facility for emergencies (the number of beds, wheelchairs and stretchers, for example).
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