Revision to system accreditation option requires 100% survey of all sites providing anesthesia services.

The system accreditation option for ambulatory care organizations has been revised to require surveying of all sites providing moderate, deep, and general sedation/anesthesia. This revision is effective immediately. Launched in 2006, the system accreditation option is an evaluation approach that awards a single accreditation decision to a “system” (an organization with a corporate office or main site and multiple sites under the auspices of the main site). This approach involves Joint Commission surveyors visiting the corporate office or main site to assess systemwide policies and functions and then performing unannounced surveys at a random sample of sites within the system to assess the execution of the policies and the delivery of care. Sites traditionally have been selected based on their risk level and size. However, the sampling methodology will no longer be implemented for sites performing high-risk invasive procedures, surgery, or anesthesia services (including moderate or deep sedation)—that is, all of these sites now require onsite surveys. Once performed exclusively in hospitals, surgical and complex invasive procedures are now performed more and more often in outpatient settings. This revision, which is intended to address the potential risks associated with the administration of these services, such as infection prevention and control, and to enhance quality of care, will appear in the fall E-dition® update as well as the 2014 Update 2 to the Comprehensive Accreditation Manual for Ambulatory Care. For a full explanation of the system accreditation option, please review the May 2006 Perspectives article “APPROVED: Refinements to the System Accreditation Option” (pages 4–5). Questions may be directed to Michael Kulczycki, executive director, Ambulatory Care Accreditation Program, The Joint Commission, at [email protected] or 630-792-5290. P