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Surgery Center policies and procedures support the surgery center to achieve the standard of care recognized by the accreditation program and CMS. The surgery center must adopt written policies and procedures that describe the processes and requirements to meet the conditions for coverage. To meet conditions for coverage the surgery centers policy and procedure manual must focus on specific significant chapters that depict the surgery center setting.
These chapters must include:
Administrative policies and procedures are established to describe and regulate management activities of the surgery center.
Anesthesia Services describes those services which facilitate diagnostic, therapeutic and surgical procedures and to ensure that the service is performed in a safe and sanitary environment by qualified health care providers who have been granted privileges from the Governing Body.
Central Supply & Sterilization
Central Supply and Sterilization policies and procedures describe standards for in-center sterilization.
Emergency Management policies and procedures are established to describe processes for maintaining surgery center and building fire safety features and handling all emergencies and disasters that can occur.
Environment of Care
Environment of Care policies and procedures are established to provide processes to identify the surgery center vulnerabilities, strengths, risk process and handling all emergencies, hazards and disasters that can occur. These policies and procedures described in this chapter are highly relevant to a Joint Commission inspection or State Licensing.
Governance policies and procedures are established to ensure that the surgery center’s Governing Body is responsible for the organization and describes its Bylaws, functionalities & management plan and rules and regulations.
Infection Control policies and procedures are established to ensure that health care services rendered are adhering to safe practices and it’s programs are designed to provide a sanitary environment with regards to prevention of infections and communicable diseases.
Medical Staff Membership
Medical Staff Membership policies and procedures are established to ensure and describe the process for credentialing and privileging of health care professionals with regards to validating the health care professional qualifications.
Medications Management policies and procedures are established to ensure and describe how the appropriate standards and practices are maintained regarding the management and administration of medications for the safety of practice as it relates to medication management and administration.
Peri operative Care policies and procedures are established to describe and ensure that the surgery center’s clinical staff facilitates quality health care services in accordance with current standards of care and principals of professional and ethical conduct.
Quality Improvement policies and procedures are established to ensure that the surgery center’s strives to improve quality of care with emphasis on providing data driven outcomes in a detailed and organized way.
Biologicals and Chemical Safety
Biologicals and Chemical Safety describes and provides policies to safely control hazardous materials, waste and chemicals.