Tasks that must be completed in order for your surgery center to become accredited by compliancedoctor

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Medical Staff Bylaws in PnP r signed.

Governing body minutes in manual and signed.

Mission statement framed and displayed.

Goals and objectives written and in governing body manual.

Organizational chart completed.

Organizational chart documented in minutes of governing body.

Goals and objectives reviewed with staff and documented in staff meeting minutes.

Policies and procedures mentioned in governing body minutes and approved.

Organizational charts reviewed with staff and documented in staff meeting minutes.

Policies and procedures signed by the chairman of the board and the medical director.

Quality book and reporting systems developed.

Quality mentioned in the governing body minutes and approved.

Audit of financial matters in policy and procedure manual.

Patients rights policy developed.

Patient rights framed and displayed for public view.

Equipment and general maintenance (contracts) book developed with table of contents.



Written hospital transfer agreement obtained.

Transfer of patient to hospital policy and procedure.

In-service documented of staff reviewing transfer of a patient to the hospital.

Business office manual complete.

Business office staff in serviced on all business functions.




PnP: Policy and Procedure Manual
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Transfer paperwork and forms completed for patient being transferred to the hospital.

Laboratory contract signed and in contract book.



Procedure for emergency lab written.



Procedure for emergency radiology written.

Procedure for emergency pharmaceutical services written.

Staff in-service for emergency lab, radiology, and obtaining of pharmaceuticals for patient.

Risk management form developed.

risk management reporting system developed.

staff in-serviced on risk management

Outcome review developed

Patient satisfaction survey developed.
Patient satisfaction policy and procedure developed dealing with patient, vendor, and physician
complaints,

governing body meeting schedule developed.

credentialing process developed.

credentialing meeting held/ documented/ minutes.

Policy on continuing education requirements of the staff.

Personnel files complete.

Medical records policy and procedure manual completed.

Medical records release of information form developed.

Staff in-service on release of medical records/ confidentiality.

List of services available developed/ in governing body manual.

Policy and procedures on treatment of minors developed.

Standards of patient conduct and responsibility developed.

Policy and procedures for 23-hour care developed.

Fees for service policy developed.

Payment policy developed.

Plan for educating patients on insurance and payment policy.



PnP: Policy and Procedure Manual
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Patient rights concerning experimental/ research developed.

Display of policy on who to and how to complain about care and financial responsibility.




Marketing policy and procedure concerning enforcement of policies and procedures of the facility
and governing body developed.




Policy and procedure concerning maintenance of equipment.




Job descriptions of all staff members complete.

policy and procedure concerning equipment care and storage.

Policy and procedure book complete with table of contents.

Identifying each section and each policy.

All staff in serviced on policy and procedure manual with minutes to document.

Personnel file contains signed job description for each employee.

New Orientation Program Developed with form to be maintained in the employee file with other
documentation.



Orientation form completed and in every employee personnel file.

Competencies developed for all professional staff.

Competencies completed by all professional staff and in personnel files.

minimum staffing policy developed for each area of ASC.


Policy on how and who is to contact patient for any problem. Abnormal lab, radiological findings,
pathology findings, etc.

Specialty consultation service list developed.

CPR class/ documentation of CPR in every personnel file.

Infection c
								
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