When I’m on an accreditation survey for AAAHC, one of the most frequently misunderstood CMS Conditions for Coverage and AAAHC accreditation chapters pertains to Governance. So what are the main components to governance of a surgery center?

Let’s start with the CMS Condition for Coverage §416.41 Condition for Coverage: Governing Body and Management

The ASC must have a governing body that assumes full legal responsibility for determining, implementing, and monitoring policies governing the ASC’s total operation. The governing body has oversight and accountability for the quality assessment and performance improvement program; ensures that the facility policies and programs are administered so as to provide quality health care in a safe environment; and develops and maintains a disaster preparedness plan.

What does this say in terms we can all understand:

The ASC must have a designated governing body that oversees and assesses all ASC activities and is responsible for:

1. Establishing the ASC’s policies

2. Making sure that the policies are implemented

3. Monitoring internal compliance with the policies

4. Assessing those policies periodically to determine whether they need revision.

In particular, the governing board must have direct oversight of:

1. The ASC’s quality assessment and performance improvement (QAPI) program

2. Quality of the ASC’s health care services

3. Safety of the ASC’s environment

4. Development and maintenance of a disaster preparedness plan

What in particular does the governing board need to do?

• The governing board must determine the mission, goals and objective for the organization.

• It must assume financial management and accountability.

• It must develop a risk management plan and accountabilities.

• It must delegate leadership and management roles. This is no minor responsibility – take a look at a list of the usual suspects:

° Administrative/leadership roles

° Human Resources

° Medical staff credentialing and granting of privileges

° Management of surgical services

° Management of nursing services

° Management of pharmaceutical services

° Management of laboratory (if applicable) and radiologic services

° Management of the ASC’s physical plant

° Quality Assurance and Performance Improvement

° Medical records maintenance

° Infection control

• Along with designation of responsible employees, items that need to be reviewed annually include:

° Rights of patients

° Delegated administrative responsibilities

° Quality of care

° The quality management and improvement program

° The organization’s policies and procedures

° The medical staff’s appointment/reappointment process

° The infection control program

° The safety program.

° Compliance with all other applicable Standards

• Most importantly, all of these jobs can be done by one or many; the key is the activity of delegation and a plan of recognition of accountability for each assigned task through a reporting mechanism.

What are some of the other accountabilities of the Governing Board

• It must formally adopt the organization’s policies and procedures, including the medical staff bylaws.

• It must have oversight of all contracts.

• It must assist in the development of a Disaster Preparedness Plan.

1.This is so important that it has its own CMS standard §416.41(c) Standard: Disaster Preparedness Plan. CMS has been very descriptive with this particular standard. It states: “The ASC must maintain a written disaster preparedness plan that provides for the emergency care of patient, staff and others in the facility in the event of fire, natural disaster, functional failure of equipment, or other unexpected events or circumstances that are likely to threaten the health and safety of those in the ASC.”

2.The ASC coordinates the plan with state and local authorities, as appropriate.The ASC conducts drills, at least annually, to test the plan’s effectiveness. The ASC must complete a written evaluation of each drill and promptly implement any corrections to the plan.

3.Lastly, the Governing Board must have control of the financial well-being of the surgery center.

The next question is how

• Perhaps the easiest and best way to meet the governance requirements is to create really good governing board meeting minutes. How do we do that?

° Start with a good template for the agenda, have consistent topics for review, clarifications and new considerations. Use the same agenda every time, it helps consistency.

° Identify what the Board wants to assess at meetings and develop a document that will review the required and specific topics in regards to your surgery center and open it for discussion at the meetings. Remember, this is your surgery center: fine tune what needs to be discussed; the minutes don’t need to review the specifics of the discussion only the high points.

• Hold regular meetings. A governing board must meet at least once a year. This type of frequency is common with single specialty, one-owner facilities. Some governing boards meet as often as monthly. Basically, the governing board should meet as often as needed to accomplish the routine work defined above. The governing board must make sure that “policy” is being followed; often this is done through quality reporting data that will be reviewed at the board meetings.

• Maintenance of contracts is easily accomplished by adding the line item “contracts” to the agenda. If you’re undergoing an accreditation survey, the surveyors don’t necessarily need to know the nitty gritty of these contracts; they just need to verify documentation that they were discussed by the governing board and quality is being maintained.

• Lastly, benchmarking is a great way to review financial well-being of your surgery center; there are several resources available for benchmarking statistical information.

In conclusion, the governing board’s responsibilities are extensive and varied. Keys to success include: having physicians that are passionate about the surgery center on the board; have leadership staff that wants to be the best; and inform the staff [all the staff – physicians to nurses to clerical] of the role of the governing board, its duties and responsibilities, and expectations. And keep a copy of the accreditation standards on your desktop for review.

Sandy Berreth has been a RN for over 35 years in multiple areas of the healthcare arena, the last 15 years as an administrator in a free-standing ASC. She holds a master’s degree in business organization and management, a CASC certification, and is a member of the BASC board for the promotion of the CASC certification. She is also a member of the ASCA Board and Minnesota’s ASC Association Board. One of her greatest pleasures is her career as an AAAHC surveyor; she believes this opportunity has developed her understanding of federal regulations and sharpened her awareness of the accreditation processes and ASC policies and procedures.