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10.I. Surgical and Related Services: General Requirements Standards
10.I.L. If applicable, protocols for handling, maintenance, and storage of blood or blood products for transfusion and/or human cells or tissues for transplantation are present.
10.I.L.3. Written protocols are consistent with a recognized authority (eg, AATB, FDA)
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10.I. Surgical and Related Services: General Requirements Standards
10.I.A. Surgical procedures must be performed in a safe manner by qualified physicians who have been granted clinical priveleges by the governing body of the ASC in accordance with approved policies and procedures of the ASC.
10.I.A. Resources
10.I.B. Surgical procedures performed are limited to those approved by the governing body upon the recommendation of qualified medical staff.
10.I.B. Resources
10.I.D. The ASC must develop and maintain a policy regarding the requirement for medical history and physical examination prior to surgery.
10.I.D.1. Completion of history and physical 30 days before surgery
10.I.D.3. Based on standards of practice, guidelines, and applicable laws
10.I.F. The ASC must ensure each patient has the appropriate pre-surgical and post-surgical assessments completed, and that all elements of the discharge requirements are completed.
10.I.F.1. Presurgical assessent completed by the surgeon/qualified physician
10.I.F.2. Include documenation of allergies to drugs and biologicals
10.I.F.3. History and physical in the patient's record before surgery
10.I.G. Informed consent for the proposed procedure is obtained.
10.I.G.1. Documentation of discussion of the proposed procedure and alterative treatments
10.I.G.2. Written consent obtained before surgery
10.I.J. The organization has written policies regarding the procedures and treatments offered to patients.
10.I.J.3. Post-procedural care
10.I.L. If applicable, protocols for handling, maintenance, and storage of blood or blood products for transfusion and/or human cells or tissues for transplantation are present.
10.I.L.2. Written protocols for handling, maintenance and storage of human cells
10.I.L.3. Written protocols are consistent with a recognized authority (eg, AATB, FDA)
10.I.M. A written policy is in place for assessing the risk of, and implementing practices to prevent, deep vein thrombosis when appropriate for the patient.
10.I.M. Resources
10.I.O. Attire contaminated with blood or body fluid is laundered by an approved laundry.
10.I.O.1. Laundry facility adheres to national guidelines
10.I.O.2. Laundry facility is approved by the organization
10.I.P. The surgical environment contains safeguards to protect patients and others from cross-infection.
10.I.P.1. Policies define OR attire
10.I.P.2. Policies address aseptic technique
10.I.P.3. Policies address removal or covering of the patient's clothing
10.I.P.4. Policies require donning of freshly laundered attire
10.I.P.5. Policies address surgical hand antisepsis
10.I.P.6. Policies address surgical site antisepsis
10.I.P.7. Temperature, humidity, and air pressure controls follow nationally recognized guidelines
10.I.Q. If procedures requiring counts of sponges, sharps, and instruments are performed, a written policy for conducting counts is present.
10.I.Q.1. Address types of procedures that require counting
10.I.Q.2. Require a count before the start of the procedure and before skin closure
10.I.Q.3. Address reporting counts to the surgeon
10.I.Q.4. Document counts in the patient's record
10.I.Q.5. Actions if the count is not correct
10.I.Q.6. Confirm the policy is followed
10.I.R. Prior to the surgery or procedure, the intended procedure is verified.
10.I.R.1. Written verification policy
10.I.R.2. Patient or authorized representative participation
10.I.R.3. Documentation of verification
10.I.S. Prior to a surgery or procedure involving level or laterality, the site is marked.
10.I.S.1. Written site marking policy
10.I.S.3. Patient or authorized representative participation
10.I.S.4. Marking by the surgeon or team member
10.I.S.5. Documentation of site marking
10.I.T. A time-out is conducted immediately prior to beginning a procedure.
10.I.T.1. Provider responsibility for the time out
10.I.T.2. Full team engagement in the time out
10.I.T.3. Verify patient, procedure, site, equipment, and implants
10.I.U. The findings and techniques of a procedure are accurately and completely documented immediately after the procedure.
10.I.U.4. Documentation of preoperative antibiotics
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Element of Compliance
Written protocols are consistent with a recognized authority (eg, AATB, FDA)
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