Skip to main content

COVID-19 RESPONSE: Recent developments are impacting our valued clients. Read these helpful resources for navigating this crisis in your business.

Check It Off: Annual Evaluations for ASCs to Perform

Wednesday, January 9, 2019 9:00 AM

BSM Products and Services, Expert Advice, ASCs

Written by: Debra Stinchcomb

Debra Stinchcomb
Senior Consultant

As one year draws to an end and a new one begins, setting and completing goals often becomes top-of-mind. For those of us in the ambulatory surgery center (ASC) industry, there are many annual items to complete, though the month in which they are completed is not mandated.

Your goal is to ensure all your annual evaluations are complete and done consistently year-after-year. For example, if you completed your assessments in January 2018, be sure to complete them again in January 2019. Additionally, it is imperative that you document each review in your governing body meeting minutes — if it wasn’t documented, it wasn’t done!

Required Annual Evaluations

The following is a list of annual evaluations required for ASCs. If you are compiling a comprehensive list for your records, be sure to add any reviews that may be mandated by your state licensing agency.

Tuberculosis (TB) Risk Assessment. In most cases, the annual completion of this risk assessment will ensure you are considered a low-risk facility. If this is the case, or has already been established, then conducting annual TB testing is likely not mandatory. However, your state regulations may trump this, so be sure to check with your state prior to stopping annual testing.

Infection Control (IC) Risk Assessment. This should be reviewed/revised every year, taking into account any changes in your setting or procedures. In recent years, this assessment has become more robust. To aid your review process, we have included a sample ophthalmic infection control risk assessment for your convenience. As always, it can (and should) be customized to fit your needs.

Quality Assurance and Performance Improvement (QAPI) Program. Medicare conditions for coverage mandates your infection control program is part of your QAPI program, so it should be easy to combine the two. For this evaluation, review and document the effectiveness of your QAPI program.

Policies and Procedures. To ensure this remains a living document, make it a point to review, edit, and approve all your facility’s policies and procedures annually. You should have an adoption page or approval section in the front of your policy manual(s) to document the date of review.

Emergency Management Plan (EMP). Be sure to review and document the effectiveness of your emergency management plan, which should account for both natural and man-made disasters. To help you evaluate your plan, ask the following questions: Have the threats facing your facility changed in the past year? What did you learn from your drills that may be opportunities for improvement? Adjust your EMP accordingly to ensure you are prepared in the face of a threat or precarious situation.

Hazard Vulnerability Analysis (HVA). As part of your EMP, you need to apply an all-hazards approach and have a HVA to assess facility- and community-based risk. There are many different HVA formats, and one version is not required over another. Please reference this sample hazard vulnerability analysis to gain insight as to what will meet the “all-hazards assessment” requirement of CMS.

Contracted Services. You are required to assess the quality of your contracted ancillary services — services that are at “arm’s length” in providing care for your patients. Examples include your pharmacy consultant, HVAC (heating, ventilation, and air conditioning) company, compounding pharmacy, and housekeeping. Each vendor must be reviewed in writing, and it is recommended that you have supporting documentation (i.e., an Office of Inspector General (OIG) search and a copy of the vendor's liability insurance face sheet) demonstrating quality.

Risk Assessments (per Accrediting Body). Your accrediting body may require additional risk assessments and reviews to those listed above. For example, you may need to review the following:

Furthermore, both AAAHC and TJC require a review of your annual operating budget.

Here to Help

As you can see, the list of comprehensive assessments that needs to be completed annually by ASCs is extensive. The Progressive team is here to help and can provide you with examples, templates, and coaching to assist with all the aforementioned reviews. What better time to schedule these assessments — or check them off your list — than at the beginning of the year?

NEED ASSISTANCE? Contact the Progressive team at 855-777-4272 or They’re happy to assist you with your efforts to meet your ASC annual evaluation requirements.

No Comments

Add a Comment