Surgery Center's Standards of Practice

Chapter One: Administration

Section 1.1: Corporate Practice of Medicine

Arizona Center for Minimally Invasive Surgery assures that this facility abides by all applicable Arizona Business & Professions Codes, including Prof. & Bus. Codes C2400 (“corporate practice of medicine”) which states that the ownership of facility is clearly defined in appropriate documents.

Section 1.2: Physician Owner and Referrals

The corporation also ensures that the facility abides by Bus. & Prof. code 650.01 & 605.02, known as the “Physician Ownership and Referral Act of 1993”, which prohibits physicians from referring patients for certain services if the physician has a financial interest or relationship with the person or entity who receives the referral.

Section 1.3: Federal and State Laws

The facility and all principals, employees and staff abide by all applicable Federal and State laws.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; General Employment Policy, P. 28

Section 1.4: MEDICAL BOARD OF ARIZONA Probation Restrictions

All physicians on staff at the facility follow MEDICAL BOARD OF ARIZONA probation restrictions, as to activities in the facility.

a. When a health care provider providing services to patients at this facility is on probation with the relevant state licensing or certification agency, the facility, its medical director and all other relevant personnel are informed of the conditions of probation. The facility assures that the provider does not violate the terms of probation in any activities carried out at, or on behalf of, the facility.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Governing Body, P. 10

Section 1.5: Notifying AAAASF, DHS, and CMS of Adverse Actions Taken Against Facility

This facility will notify AAAASF, DHS, and CMS within 10 days of any adverse action taken against the facility or one of its medical staff members, by any other entity, that affects the ability or capacity of the facility to provide anesthesia in doses that, when administered, have the probability of placing a patient at risk for loss of the patient’s life-preserving protective reflexes. Such adverse actions, include, but are not limited to:

a. Suspension, restriction or revocation of the facility’s surgical clinical licensed issued under subdivision (b) of Arizona Health & Safety Code, section 1204

b. Any restriction, probation, suspension, termination or denial of accreditation imposed by any other private accrediting entity, including The Joint Commission, American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (AAAHC) or the American Osteopathic Association (AOA) pursuant to Health & Safety Code 1248 et seq.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Governing Body, P. 10

Section 1.6: Governing Body

The Medical Director shall be responsible for all clinical decisions at Arizona Center for Minimally Invasive Surgery.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix B: Medical Director Job Description, P. 318

Section 1.7: Medical Director Job Description

Arizona Center for Minimally Invasive Surgery has a Medical Director. The Medical Director Job Description is contained in the personnel record.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix B: Medical Director Job Description, P. 318

Section 1.8:Administrator Job Description

The facility’s Administrator is responsible for the day-to-day- operations of the office and for the management of fiscal matters. The Administrator’s job description is contained in the personnel file.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix C: Administrator Job Description, P. 319

Section 1.9:Scope of Services Provided

The Arizona Center for Minimally Invasive Surgery Scope of Procedures is complete, appropriately performed and periodically reviewed and amended as appropriate. The procedures are appropriate to the facility and its available instruments and the staff’s training and expertise. The Scope of Procedures is amended as new procedures are approved or as procedures are deleted from the list of surgical services to ensure the list is current and relevant to the specialties and practices of the medical staff. The Scope of Procedures is reviewed at least annually and a current, signed and dated copy is kept at Arizona Center for Minimally Invasive Surgery and can also be found in the Arizona Center for Minimally Invasive Surgery Policy and Procedures manual.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0: Surgical Services; Scope of Services Provided, P. 70

Section 1.10: Patient Waiting Areas

Arizona Center for Minimally Invasive Surgery is seeking to meet CMS Life Safety Codes as well as the CMS Regulations that allow for us to become a Medicare Certified Facility. Therefore, the waiting area for post-operative patients is separate from the office waiting area and has a private entrance that is not visible from the office waiting area.

Section 1.11: Clinical Procedures and Protocols

Standardized clinical procedures for nurses shall be developed in consultation with, and signed by, the physician owner and Medical Director.

Section 1.12: Accreditation Certificate, State License

All accreditation certificates, State Licenses, Certificates, Waivers presented to Arizona Center for Minimally Invasive Surgery by any accreditation entity, licensing division, or any subsection of any part of these entities will be posted in the lobby of the surgery center.

Section 1.13: Regulatory Agency Information

The name and phone number of all agencies who have regulatory oversight of this facility will be posted in a location readily visible to patients and staff, along with instructions for the submission of complaints. This is all contained within our patient rights and responsibilities (aka: Bill of Rights) that each patient receives prior to any surgery-taking place.

Section 1.14: AAAASF Notification of Survey

The AAAASF Notification of Accreditation Survey will be posted in a readily visible location for no less than thirty days prior to the survey.

Section 1.15: Patient Information Materials

Patient information materials, including patient brochures, the Arizona Center for Minimally Invasive Surgery website, and advertisements, are reviewed by the Governing Body on an annual basis or whenever significant changes take place at Arizona Center for Minimally Invasive Surgery.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Governing Body, P. 10

Section 1.16: Patient Rights and Responsibilities

Arizona Center for Minimally Invasive Surgery honors and respects patient rights and responsibilities. Arizona Center for Minimally Invasive Surgery’s Patient Rights and Responsibilities are posted in the lobby area and provided to each patient in writing upon first registering with Arizona Center for Minimally Invasive Surgery.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix D: Patient Rights and Responsibilities (clinical form), P. 319

Section 1.17: Advanced Directives Policy

While Arizona Center for Minimally Invasive Surgery does not treat life-threatening illnesses or elderly patients, Arizona Center for Minimally Invasive Surgery has an Advanced Directives Policy.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0: Emergency Procedures; Advanced Directives, P. 65

Section 1.18: Patient Complaints

Arizona Center for Minimally Invasive Surgery has a clear process for patients to express their concerns and report problems and has identified specific personnel to address and respond accordingly. The Arizona Center for Minimally Invasive Surgery staff knows the procedure for handling a patient concern and is aware of the need for confidentiality in these situations.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Addressing Patient, Family and Visitor Complaints, P. 26

Section 1.19: Interpreters

If there is a language or other communication barrier impacting communication between Arizona Center for Minimally Invasive Surgery and a patient, every effort will be made to have an interpreter available. If there are no employees on staff who can interpret for the patient, the patient will be asked to bring a friend or family member to interpret for them and the interpreter name will be documented in the patient chart. If a professional interpreter is retained for the appointment, the name and source of the interpreter will be documented in the patient medical record.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0: Nursing Services, Staffing Patterns and Responsibilities, P. 126

Section 1.20: Office Scheduling Policy

Scheduling and prioritizing of appointments is based upon the clinical needs of the patient.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0: Nursing Services; Office Scheduling Policy, P. 125

Section 1.21: Scheduling and Prioritizing of Telephone Messages

Scheduling and prioritizing of telephone messages is based upon the clinical needs of the patient.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0: Nursing Services; Office Scheduling Policy, P. 125

Section 1.22: 24-Hour clinical Coverage

There is 24-hour coverage for the center. Surgical patients are given information for reaching their physician and nursing staff during the non-operating hours.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0: Nursing Services; Office Scheduling Policy, P. 125

Appendix E: Outpatient Responsibility and Caregiver Instructions for Office Surgery (clinical form), p. 321

Appendix f: Post-Operative Care for Micro-Body Contouring (clinical form), p. 322

Section 1.23: Follow-Up on Missed Appointments

Arizona Center for Minimally Invasive Surgery ensures follow up on cancelled or missed appointments based on clinical need and this follow up is documented in the patient record.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0: Nursing Services; Office Scheduling Policy, P. 125

Section 1.24: Systems and Staff to Ensure Accurate Patient Billing

Arizona Center for Minimally Invasive Surgery employs uniform systems and trained personnel to ensure accurate and timely patient billing. The Practice’s Administration Policy and Procedures Manual contains established written procedures to monitor submitted bills to verify accuracy.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Fees, Copays and Deductibles, p. 20

Section 1.25: Ensuring Patient Understands Fees

Patients will be provided with a written quote for any services recommended by councilors or medical staff, and the quote will be explained thoroughly to the patient. The patient will have an opportunity to ask questions prior to signing the quote and a copy of the quote will be kept in the patient record.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Fees, Copays and Deductibles, p. 20

Appendix P: Procedure Quote (clinical form), p. 332

Appendix Q: Insurance Release (clinical form), p. 333



Chapter Two: Personnel and Credentialing

Section 2.1: Employee Training and Orientation

Employees at Arizona Center for Minimally Invasive Surgery are trained and supervised by the Director of Nursing working in conjunction with the Medical Director. New employees receive orientation and new hiring training that is appropriate to the duties of their job, including but not limited to:

a) Confidentiality of patient information

b) Fire and life safety equipment and emergency drills

c) OSHA Blood-Borne Pathogen Standards

d) Maintenance and operation of equipment within their scope of practice

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; General Employment Policy, p. 28

Section 2.2: Staff In-Service Training Based on Patient Satisfaction Surveys

Patient Satisfaction Surveys are conducted regularly and the Administrator is provided detailed results from the survey respondents. The Administrator holds periodic staff meetings during which the results of the surveys are discussed and training is conducted on areas where improvement is deemed necessary.

Staff education is an ongoing part of the regular staff meetings and in-service training is provided on issues that impact patient care and staff ability to perform their jobs. Documentation of specific in-service training is maintained in the employee file.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 9.0: Continuous Quality Improvement; Patient Satisfaction Surveys, p.309


Section 2.3: Employee policies and procedures

All Arizona Center for Minimally Invasive Surgery employees receive an employee handbook on their first day of work. Each employee is required to read the handbook thoroughly and sign an acknowledgment page indicating they have done so and understand the policies and procedures contained therein.

The Policies and Procedures contained in the Employee Handbook address:

a) Hiring and dismissal of staff;

b) Performance expectations and competency;

c) Training;

d) Expected working hours;

e) Sexual harassment prohibitions;

f) Patient privacy and confidentiality; and

g) Management of the impaired practitioner

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix R: Arizona Center for Minimally Invasive Surgery Employee Handbook, p. 334

Section 2.4: Staff Responsibilities

At the time of hire, each Arizona Center for Minimally Invasive Surgery employee is presented a written job description outlining his or her responsibilities. The job description is signed by the employee and kept in the employee’s personnel file. These job descriptions are reviewed regularly and updated as deemed appropriate by the Administrator, Medical Director, Director of Nursing, and/or corporate Human Resources department. When an employee’s job description is amended, the employee is asked to sign the amended job description and is given a copy. A copy of the amended job description is also kept in the employee’s personnel file.

All Arizona Center for Minimally Invasive Surgery health care providers understand the responsibilities of the other members of the health care team so that working relationships can be fostered among the team that will contribute to the success of the practice.

Section 2.5: Name Tags

Nametags are required to be worn by all Arizona Center for Minimally Invasive Surgery employees at all times the employee is at the facility. The name tags are produced in 18 point type and for healthcare providers, the name tags also include the practitioner’s license status.


Standard 2.6: Employee Job Descriptions

At the time of hire, each Arizona Center for Minimally Invasive Surgery employee is presented a written job description outlining his or her responsibilities. The job description is signed by the employee and kept in the employee’s personnel file. These job descriptions are reviewed regularly and updated as deemed appropriate by the Administrator, Medical Director, Director of Nursing, and/or corporate Human Resources department. When an employee’s job description is amended, the employee is asked to sign the amended job description and is given a copy. A copy of the amended job description is also kept in the employee’s personnel file.

The Governing Body, Medical Director, Director of Nursing and Human Resources department are responsible for ensuring the job descriptions are consistent with applicable state regulations and are within the employee’s scope of practice.

Standard 2.7: Personnel Files

Personnel files are maintained for every Arizona Center for Minimally Invasive Surgery employee. The personnel file includes documentation of education, training and confidentiality statements, as well as a current job description that has been signed by the employee.

Standard 2.8: Documentation of State Licensure, Registration and Certification

The personnel files for employees that provide clinical service include current and valid copies of required documentation, including license, education and any additional training or certifications, and health records. A copy of valid picture ID is maintained in all employee files. All employee files contain a checklist of required documentation and expiration dates of licenses and certifications.

Standard 2.9: Registry Nurses or Technicians

When using registry nurses or technicians, Arizona Center for Minimally Invasive Surgery will:

a) Confirm the registry employee’s identity with a picture ID and keep a copy of the clinical license and ID verification on file;

b) Ensure that verification of licensure, credentials and competency has been performed by the registry company;

c) Provide appropriate orientation for all registry staff.


Standard 2.10: Documentation of Each Independent Practitioner’s State Licensure and Drug Enforcement Administration Registration is On site and Current

Arizona Center for Minimally Invasive Surgery ensures that a file for all independent practitioners is current. At the time of employment of an independent practitioner, the Human Resources Department verifies licensure and obtains copies of all licenses and certificates, including medical licensure and DEA certification, for the personnel file.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Clinical Privileges, p.13

Standard 2.11: Independent Practitioner Files

The personnel files for independent practitioners include the following:

· Verification of education, training, board eligibility or certification;

· Proof of current professional liability insurance

· A list of privileges granted by the facility

· Evidence of current membership on the medical staff of an accredited facility not owned or operated by the practitioner, such as hospital credentials or privileges

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Clinical Privileges, p.13


Practice Standards = Quality in Care

Standard 2.12: Professional Liability Coverage for Physicians (Medical Malpractice)

Arizona Center for Minimally Invasive Surgery requires physicians to carry medical malpractice insurance at a minimum coverage of $1,000,000 / $3,000,000. Evidence of coverage is obtained upon employment of physicians and a copy of the insurance coverage and a current loss run report spanning five years is placed in the personnel file.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p.317

Section 2.13: Granting Privileges

Privileges are granted in accordance with recommendations from qualified health professionals and using established credentialing standards. Practitioners are professionally qualified and appropriately credentialed for the performance of privileges granted.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Clinical Privileges, p.13

Standard 2.14: Proctoring Policy

Arizona Center for Minimally Invasive Surgery physicians are subject to a period of on-site proctoring. This standard is waived only if the practitioner has similar specific clinical privileges without proctoring, granted by an accredited acute care hospital or ambulatory care facility with an organized medical staff as he/she is requesting from Arizona Center for Minimally Invasive Surgery. The practitioner may not be an owner or operator of the other accredited facility.

If the practitioner does not have privileges from an accredited facility, then a physician with a similar specialty must do the proctoring on site.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Proctoring Policy, p.12

Standard 2.15: Reappraisal of Clinical Privileges

The clinical privileges granted to physicians by Arizona Center for Minimally Invasive Surgery are reappraised at least every three years, at which time an assessment is made of the following areas:

Physician’s performance at facility

a) Clinical judgment

b) Skill

c) Competence

d) Experience

e) Training

f) A copy of the assessment is placed in the physicians’ personnel file.

The Medical Director of an Arizona Center for Minimally Invasive Surgery facility may grant him/herself privileges in accordance with Arizona Center for Minimally Invasive Surgery’ Peer Review Policy, in which case the peer reviewer will co-sign a letter granting privileges and this letter will be maintained in the personnel file.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Clinical Privileges, p.13

Standard 2.16: Medical Bylaws

Arizona Center for Minimally Invasive Surgery medical staff operates under the guidance of the written Arizona Center for Minimally Invasive Surgery Medical Staff Bylaws. The Bylaws are provided to all medical staff and a copy is maintained at the facility.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p.317

Standard 2.17: Criteria and Standards for Admission to and Continuing Membership on the Arizona Center for Minimally Invasive Surgery Medical Staff

Arizona Center for Minimally Invasive Surgery’ Medical Staff Bylaws establish specific criteria and standards for admission to and continuing membership on the organized medical staff and the Bylaws contain provisions for processing and verification of applications to the medical staff.

Initial applicants are required to provide evidence of the following:

a) Education

b) Professional training

c) Current Arizona license to practice

d) DEA registration

e) Training and experience for the services requested

f) Two peer references

g) A signed consent for the release of information necessary for verification of the application

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p.317

Standard 2.18: Credentialing Policy

Upon completion of the application, the physician’s licensure and DEA certificate are verified by Arizona Center for Minimally Invasive Surgery with the primary source. The Human Resources verify credentials for the medical staff’s department and a physician credential check list is completed and placed in the personnel file.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p.317

Standard 2.19: Reappointment to the Medical Staff and Reappraisal of Privileges

Arizona Center for Minimally Invasive Surgery’ Medical Staff Bylaws define the process and frequency for reappointment to the medical staff and reappraisal of privileges. Per the Arizona Center for Minimally Invasive Surgery Medical Staff Bylaws, reappointment is required at least every two years.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p.317


Standard 2.20: Peer Review Determinations Included in Reappointment Process

Arizona Center for Minimally Invasive Surgery’ Medical Staff Bylaws require that Arizona Center for Minimally Invasive Surgery’ Peer Review Committee participate in the assessment for reappointment to the staff.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p.317

Standard 2.21: Granting Privileges

Privileges are granted to Arizona Center for Minimally Invasive Surgery physicians in accordance with recommendations from qualified health professionals and using established credentialing standards. Practitioners are professionally qualified and appropriately credentialed for the performance of privileges granted.

Arizona Center for Minimally Invasive Surgery has a policy for documenting and granting privileges and each practitioner’s credential files has a copy of the approved clinical privileges granted to that practitioner.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Clinical Privileges, p.13

Standard 2.22: Governing Body Approval of Privileges

Arizona Center for Minimally Invasive Surgery’ governing body reviews and approves all clinical privileges granted.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Governing Body, p. 10

Standard 2.23: Documentation of Privileges Granted

The physician’s personnel file includes documentation of application for privileges, completion of successful proctoring and privileges granted by Arizona Center for Minimally Invasive Surgery.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Clinical Privileges, p.13

Standard 2.24: Proctoring Policy

All members of the Arizona Center for Minimally Invasive Surgery medical staff are subject to a period of proctoring.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Proctoring Policy, p.12

Standard 2.25: Privileges for Independent Health Care Practitioners

Arizona Center for Minimally Invasive Surgery’ medical staff has developed criteria for granting, restricting and terminating clinical privileges of independent health care practitioners.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p.317

Standard 2.26: Reappraisal of Clinical Privileges

Privileges granted to Arizona Center for Minimally Invasive Surgery physicians are reappraised at least every three years. At the time of reappraisal, the determination of the physician’s competence includes:

a) Assessment of physician’s performance

b) Clinical judgment

c) Skill

d) Competence

e) Experience

f) Training

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p.317



Chapter Three: Quality Programs and Peer Review

Standard 3.1: Quality Assessment and Improvement

Arizona Center for Minimally Invasive Surgery has a formal system for quality assessment and improvement. Arizona Center for Minimally Invasive Surgery medical staff actively participates in the Quality Improvement Program, which includes review of patient charts, patient satisfaction surveys and incident reports.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 9.0: Continuous Quality Improvement; Quality Improvement Program, p.305

Standard 3.2: Quality Management Program Review

The Quality Improvement Committee will annually evaluate the effectiveness of the Quality Improvement Plan and revise it accordingly. The results of this evaluation will be disseminated to the Governing Body and staff.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 9.0: Continuous Quality Improvement; Quality Improvement Committee, p.304

Standard 3.3: Facility Quality of Care

Arizona Center for Minimally Invasive Surgery’ Governing Body and administration supports the medical staff in all efforts to improve the quality of care within the facility.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Governing Body, p.10

Standard 3.4: Quality Management Program

Arizona Center for Minimally Invasive Surgery’ Quality Management Program is implemented and managed by the Quality Improvement Committee and oversees the following:

a) Safety of patients and staff

b) Infection control

c) Clinical outcomes

d) Risk management

e) Monitoring of equipment

f) Quality Improvement and analysis

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 9.0: Continuous Quality Improvement; Quality Improvement Program, p.305


Standard 3.5: Assessment of Administrative and Clinical Outcomes

Arizona Center for Minimally Invasive Surgery’ Quality Management program includes an organized, integrated plan to address administrative and clinical outcomes, including:

a) Identification of problems and concerns

b) Participation of physicians, allied health professionals, office staff and administration

c) Evaluation of the frequency, severity and source of suspected problems and concerns and evaluation of whether policies and/or procedures should be revised

d) Review of related processes and implementation of measures to address and resolve identified problems or concerns

e) Reevaluation of problems or concerns to determine objectively whether corrective measures achieved and sustained the desired results

f) Reporting of findings to the governing body

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 9.0: Continuous Quality Improvement; Quality Improvement Program, p.305

Standard 3.6: Patient Satisfaction

Arizona Center for Minimally Invasive Surgery actively assesses patient satisfaction.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 9.0: Continuous Quality Improvement; Patient Satisfaction Surveys, p.309

Standard 3.7: Risk Management Program

Arizona Center for Minimally Invasive Surgery has a risk management program to help reduce or correct practices that jeopardize patient safety.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 9.0: Continuous Quality Improvement; Risk Management Program, p.312

Standard 3.8: Quality Improvement Committee Findings

The Quality Improvement Committee regularly updates the governing body and medical and other staff on its findings by providing written reports on at least a quarterly basis. The records of the Quality Improvement Committee are confidential and access is limited to defined personnel.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 9.0: Continuous Quality Improvement; Quality Improvement Committee, p.301


Standard 3.9: Peer Review

Arizona Center for Minimally Invasive Surgery relies on peer review to determine the appropriateness of clinical decision-making and the overall quality of care at Arizona Center for Minimally Invasive Surgery. Peer review is based on objective written criteria. Specific cases that are subject to peer review are defined and peer review of these cases will be conducted on-site.

The Governing Body and the Quality Improvement Committee define qualifications for use of external peer reviewers. Only individuals who are free from all conflicts of interest and who are not professional associates of Arizona Center for Minimally Invasive Surgery are used as peer reviewers. Credential files are maintained for all outside peer reviewers and include the peer reviewer’s CV, verification of current licensure and a confidentiality statement.

The peer review process includes a review of patient records and the physician’s credentials file, and interviews. The purposes of the peer review are to identify both strengths and weaknesses among the Arizona Center for Minimally Invasive Surgery medical staff, to evaluate trends in the quality of care at Arizona Center for Minimally Invasive Surgery and to provide a plan of corrective action, when appropriate.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0: Management; Governing Body, p.10

Section1.0: Management; Peer Review, p. 14

Section 9.0: Continuous Quality Improvement; Quality Improvement Committee, p. 301

Standard 3.10: Peer Review Records

Peer review activity is confidential. The records resulting from the peer review process, including conclusions, recommendations and actions taken, are secure and access to them is limited to defined personnel.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Peer Review, p. 14

Standard 3.11: Peer Review Frequency

Peer review occurs at least quarterly unless a significant event occurs that requires an expedited peer review.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Peer Review, p. 14


Standard 3.12: Expedited Peer Review

An expedited peer review will be conducted within seven days of any death, unplanned transfer to acute facility, significant complications and/or any other unexpected event with adverse clinical consequences.

Arizona Center for Minimally Invasive Surgery will notify AAAASF within twenty four hours of the death of a patient that occurs within 7 days of a procedure, regardless of where the death occurred.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Peer Review, p. 14

Standard 3.13: Peer Review Results and Medical Staff Membership

Peer review results are maintained in a separate file from the physician’s regular personnel file. The results of peer review are considered when granting medical staff membership and clinical privileges at Arizona Center for Minimally Invasive Surgery.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p. 317

Standard 3.14: Standards for Peer Review

Arizona Center for Minimally Invasive Surgery’ Medical Staff Bylaws contain standards for peer review that is based on objective clinical criteria and has the following elements:

a) Identification of strengths and weaknesses, and a plan of corrective action when appropriate

b) Evaluation of trends in quality of care

c) Evaluation of the appropriate utilization of diagnostic services

d) A mechanism to refer cases from peer review to the Quality Improvement and Risk Management Programs, and vice versa

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Appendix A: Medical Staff Bylaws, p. 317

Standard 3.15: Peer Review Meetings

Arizona Center for Minimally Invasive Surgery holds peer review meetings at least every quarter unless a significant event occurs that requires an expedited peer review. The findings of peer review meetings are distributed to the appropriate physicians and committees, including the Quality Improvement Committee and Governing Body.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Peer Review, p. 14

Standard 3.16: Peer Review Activities

Peer review activities are confidential. Records of peer review activities, including conclusions, recommendations and actions taken, are labeled as confidential and access is restricted to clearly defined personnel.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Peer Review, p. 14

Standard 3.17: Expedited Peer Review Meetings

An expedited peer review will be conducted within seven days of any death, unplanned transfer to acute facility, significant complications and/or any other unexpected event with adverse clinical consequences.

Arizona Center for Minimally Invasive Surgery will notify AAAASF, the State of Arizona DHS, and the Center for Medicare and Medicaid dfwithin twenty four hours of the death of a patient that occurs within 7 days of a procedure, regardless of where the death occurred.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Peer Review, p. 14

Standard 3.18: Filing Reports with State and National Boards

Arizona Center for Minimally Invasive Surgery files appropriate reports with the Medical Board of Arizona and the National Practitioner Data Bank when required by State and federal law.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Peer Review, p. 14

Standard 3.19: Peer Review Results and Medical Staff Membership

Peer review results are maintained in a separate file from the physician’s regular personnel file. The results of peer review are considered when granting medical staff membership and clinical privileges at Arizona Center for Minimally Invasive Surgery.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Peer Review, p. 14

Appendix A: Medical Staff Bylaws, p. 317



Chapter Four: Medical Records

Standard 4.1: System for Maintaining Clinical Records

While Arizona Center for Minimally Invasive Surgery does not use electronic health records, Arizona Center for Minimally Invasive Surgery has a system for maintaining clinical records. All personnel with access to medical records are trained on the medical record system. This system is a hard copy terminal digit system for retrieval of active and current surgical patients, and then the chart is converted into a system of complete digitalized scanning. Both systems maintain the integrity of the record and ensures ongoing retrieval should it be necessary by any legal request of third party.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.2: Medical Record format

The medical record is legible, complete and organized in a consistent format with a patient identifier on each page of the record. It also includes such things as: Advanced Directives, Consents, Financial, Allergy Status, and other critical information.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.3: Medical Record Information

Arizona Center for Minimally Invasive Surgery patient medical records are readily accessible to the health care professionals for each person receiving care and include the following patient registration information filled out by the patient or guardian, including:

a. Name

b. Date of birth

c. Address

d. Home, work and mobile phone numbers, as applicable

e. Contact information for the person designated as patient’s emergency contact

f. The patient’s billing information

g. Employer, if applicable

h. Notation of special circumstances for consideration (e.g., “hearing impaired”)

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.4: Dating and Signing Medical Record

All material in the medical record is signed, dated and timed. This applies to all entries to the medical record, including phone messages, prescriptions and consultation/diagnostic reports. All surgical dictations have the date of dictation, the date of transcription and the date of signature.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.5: Additions and Corrections to the Medical Record

Additions and corrections to the medical record are clearly indicated with the reason for the change and are dated, timed and initialed/signed. Any deletions, alterations or erroneous entries are crossed out with a single line, dated, timed and initialed with the reason for the addition, deletion or alteration documented. Errors or additions are added or altered by a correction entry with the reason for the change noted according to facility procedure. Liquid correction fluid is never used on Arizona Center for Minimally Invasive Surgery medical records.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.6: Completion of Medical Record

All medical records are completed within 30 days from the date services were provided.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.7: Retention of Medical Records

Arizona Center for Minimally Invasive Surgery retains medical records in compliance with applicable regulations and statutes. Medical records are maintained for at least seven years. Records stored off-site are maintained in a secured facility that specializes in confidential record storage.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.8: Contents of Medical Record

Arizona Center for Minimally Invasive Surgery medical records include information needed to appropriately and safely treat patients, including, but not limited to:

a) A notation on allergies/adverse reactions or the absence thereof, documented in a prominent and consistent location

b) Relevant History and Physical Exam

c) Patient’s immunization information

d) All known findings, diagnoses, treatments and documentation of physician’s review, including follow-up instructions and appointments

e) Results of laboratory, x-ray and diagnostic studies and outside consultations, operative reports, etc., authenticated and initialed by the provider

f) A problem list and individualized treatment plan and current medication lists

g) The date and time of all health encounters and reports in chronological order

h) Phone consultations when clinically relevant, including the date, time and by whom

i) Prescription and refill records with the drug name, dose, amount, date and provider

j) Consent information and informed consent documentation, refusal of care and release-of-information forms

k) Notes regarding patient refusal of care, non-compliance with treatments ordered, clinical appointments missed, etc

l) Documented preventative care

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.9: Documentation of Patient Education

Patient education regarding diagnosis, treatment, and preventive measures is documented in the medical record.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.10: Medical Records for Surgical Patients

Each Arizona Center for Minimally Invasive Surgery medical record contains the following information:

a) A current medical history and relevant physical examination (updated on the day of surgery), completed and placed in the patient’s chart prior to surgery, with an assessment and plan that includes indications for surgery and the planned operation

b) A pre-operative anesthesia evaluation to assess anesthetic risk and options

c) Written, signed consents for surgery and anesthesia

d) An operative or invasive procedure note, written in the chart promptly after the surgery or procedure, with documentation that includes:

· The pre-operative or pre-procedure diagnosis and/or indications for surgery or procedure

· The operation/procedure performed

· The name of the surgeon, assistant surgeon and provider of anesthesia

· The type of anesthesia administered

· Post-operative or post-procedure diagnosis

· The details of operation or procedure, including all findings

· Any complications or adverse outcomes

· The patient’s condition and prognosis after surgery or procedure

e) An anesthesia record or means of documenting all patient monitoring (physiologic monitoring and documentation should include, at a minimum, blood pressure, pulse rate, respiratory rate, continuous pulse oximetry, continuous electrocardiogram monitoring, and, if possible End Tidal CO2)

f) Post anesthetic note written after the patient has fully recovered from the effect of the anesthetic and documenting the presence or absence of any anesthesia related complications

g) An order form or means of documenting all medications before, during and after the surgery procedure

h) A recovery room record with documentation of monitoring

i) A pathology report authenticated by the physician

j) Copies of written pre-procedure and post-procedure patient instructions, including diet, activities and when the patient should return for follow-up appointments

k) Documentation that the post-op call occurred within 24 hours. There should be a policy that clearly defines the person(s) responsible for the post-op call.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.11: Confidentiality of Patient Information

Arizona Center for Minimally Invasive Surgery ensures strict confidentiality of all patient information.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Confidentiality of Records, p. 21

Standard 4.12: HIPAA Policy

Arizona Center for Minimally Invasive Surgery has a compliance program that is consistent with HIPAA Privacy Rules and confidentiality requirements dictated by State law.

Arizona Center for Minimally Invasive Surgery’ Privacy Policy is included in the Arizona Center for Minimally Invasive Surgery Ambulatory Care Policy & Procedure Manual and the Arizona Center for Minimally Invasive Surgery Employee Handbook. Additionally, all Arizona Center for Minimally Invasive Surgery staff receive orientation and in-service training on Arizona Center for Minimally Invasive Surgery’ HIPAA Policy and Procedures and documentation of this training is maintained in the personnel file.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Privacy Policy, p. 23

Standard 4.13: Patient Receipt of HIPAA Policy

Upon registration, each patient receives a copy of the Arizona Center for Minimally Invasive Surgery Privacy Policy and Acknowledgment , which describes Arizona Center for Minimally Invasive Surgery’ compliance with HIPAA requirements. Each patient is required to sign the Acknowledgment and the original is kept in the Medical Record.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Privacy Policy, p. 23

Appendix H: Privacy Policy and Acknowledgment (clinical form), p. 324

Standard 4.14: Posting of Privacy Practices

Arizona Center for Minimally Invasive Surgery’ Privacy Policy is posted in the front office in a spot that is readily visible to patients and staff. The Privacy Policy is also available to the public on the Arizona Center for Minimally Invasive Surgery website.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0: Management; Privacy Policy, p. 23

Standard 4.15: Medical Records Security

Arizona Center for Minimally Invasive Surgery Medical Records are accessible only to employees whose job duties require authorization to access patient information. The Medical Records are stored in a fireproof file cabinet in a locked room that is readily accessible to appropriate healthcare providers but inaccessible to patients and the public.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Standard 4.16: Release of Patient Information

Arizona Center for Minimally Invasive Surgery complies with all applicable state and Federal regulations and statutes pertaining to the release of medical, mental health and other patient information.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Medical Records Policy, p. 75

Appendix I: Patient Release of Medical Information, p. 325





Chapter Five: Care and Treatment

Standard 5.1: Informed Consent

Arizona Center for Minimally Invasive Surgery obtains informed consent from each patient for each procedure performed. Informed consent at Arizona Center for Minimally Invasive Surgery is:

a. Obtained prior to any medical or surgical procedure, except those simple and common procedures involving risks which are commonly understood to be remote, in which case a notation of verbal consent is made in the chart.

b. Documented in the medical record.

c. Obtained prior to inclusion in any research or experimental protocol in accordance with the law and standards of the medical profession.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Informed Consent, p. 74

Appendix J: Informed Consent for Micro-Body Contouring (clinical form), p. 326

Standard 5.2: Informed Consent and Family Members

When requested by the patient, Arizona Center for Minimally Invasive Surgery makes provisions to include family members and significant others in the discussion and consent process.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section3.0: Surgical Services; Informed Consent, p. 74

Standard 5.3: Staffing Patterns

Arizona Center for Minimally Invasive Surgery ensures adequate staff for the volume of patients, using the following benchmarks:

a. To allow scheduling of urgent appointments within 24 hours of request

b. To allow scheduling of specialist consultation appointments within 14 days of request

c. To allow scheduling of routine examinations within 30 days of request

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section4.0: Nursing Services; Staffing Patterns and Responsibilities, p. 126

Standard 5.4: Continuity of Care

Arizona Center for Minimally Invasive Surgery ensures continuity of care to all patients, as demonstrated by the following processes, policies and procedures:

a. The facility has in place a process to assure that the responsible physician is aware of findings of diagnostic studies.

b. All patients are contacted in a timely manner that is consistent with the patient’s clinical status with results from diagnostic testing.

c. Physician requests for consultation include the reason for the formation of a properly founded opinion, including information to which the consultant does not otherwise have access and that is important to assure appropriate medical care by the consultant.

d. Consultation reports and records are reviewed by the responsible physician in a timely fashion.

e. Patients are promptly contacted to discuss any significant results from the consultation or pathology.

f. The patient’s medical record includes summary reports of other consultations and hospitalizations.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Medical Records Policy, p. 75

Section3.0: Surgical Services; Receipt of Lab Results, p.81


Standard 5.5: Second Opinions and Referrals

Second opinions and referrals to consultants/specialists are timely and are appropriate to the patient’s clinical condition.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Second Opinions and Outside Referrals, p. 73

Standard 5.6: Patient Medical Information Provided to Outside Care Providers Upon Referral

Each patient transferred to another health care facility will be sent with copies of the following;

· Preoperative, Anesthesia, OR and RR Record including a discharge note that contains the patient’s vital signs prior to discharge

· History and Physical, pertinent reports, labs, etc.

· Discharge summary dictated by the surgeon (if not available at the time of transfer, a copy will be sent). A stat note will be done at the time of discharge if time allows

· Procedure report dictated by the surgeon will be sent as soon as it is ready.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; Transfer Policy, p. 16


Standard 5.7: Transfer of Patient to Another Provider

Although the medical care Arizona Center for Minimally Invasive Surgery provides its patients is limited in scope to specific cosmetic procedures and tends to be for a limited duration of time, should it become necessary to of transfer care of a patient to another provider, whether prompted by physician specialty, patient choice or other reasons, the transfer will be done in a professional manner with appropriate documentation forwarded to the new provider to ensure continuity of care. In such situations, the following occurs:

a. The patient is informed of the reason for transfer of care

b. A copy of the medical record or an appropriate summary is provided to the physician assuming the patient’s care.

c. All necessary actions are taken by Arizona Center for Minimally Invasive Surgery to ensure the transfer of care does not compromise the well-being of the patient.

d. The new provider(s) is notified of any special patient needs or medical problems.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; Transfer Policy, p. 16

Section 3.0: Surgical Services; Second Opinions and Outside Referrals, p. 73

Standard 5.8: Transferring a Patient to Another Facility in an Emergency

When admitting or transferring a patient to another facility in an emergency, the following occurs:

a. The physician transferring the patient notifies the receiving facility.

b. The mode of transfer is consistent with the patient’s clinical condition.

c. A family member is notified.

d. Clinical information is documented and sent with the patient.

e. If the physician does not have privileges at the facility to which the patient is being transferred, arrangements are made for medical care to be provided by physicians who do have privileges.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Transfer of a Patient to Another Facility, p. 42

Standard 5.9: Appropriate Diagnostic Testing

Arizona Center for Minimally Invasive Surgery performs diagnostic testing that is deemed by the physician to be necessary and appropriate to the care being delivered.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Laboratory Monitoring, p. 79


Standard 5.10: Patient Compliance with Diagnostic Testing

Patients are provided assistance to ensure compliance with obtaining any diagnostic tests required by Arizona Center for Minimally Invasive Surgery. Follow-up procedures are in place at Arizona Center for Minimally Invasive Surgery to ensure that the tests are completed in accordance with the physician’s orders.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Laboratory Monitoring, p. 79

Standard 5.11: Outside Diagnostic Facilities

Arizona Center for Minimally Invasive Surgery patients are required to pay separately for all diagnostic services and as such are given the option of obtaining these diagnostic services at a site of their choosing. Arizona Center for Minimally Invasive Surgery only refers patients to specific outside facilities that are appropriately licensed.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Laboratory Monitoring, p. 79

Standard 5.12: On-Site Diagnostic Services

Arizona Center for Minimally Invasive Surgery only performs point-of-service testing at its facility and a CLIA waiver is in place and posted in the nurses’ station.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Laboratory Monitoring, p. 79

Standard 5.13: Medication Errors

Arizona Center for Minimally Invasive Surgery has a policy for reduction of medication errors at the facility, which includes the following elements:

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 5.0; Pharmacy; Pharmacy Management, p. 145

Standard 5.14: Documenting Patient Medication Information

Arizona Center for Minimally Invasive Surgery patient intake paperwork requires patients to list all medications they are taking, including prescribed and over-the-counter medications and herbal remedies.

Arizona Center for Minimally Invasive Surgery physicians are trained and experienced in the management of opiate drugs, as demonstrated by their standing with the Drug Enforcement Agency and as verified in the credentialing process.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 5.0; Pharmacy; Pharmacy Management, p. 145

Appendix K: Patient Medical History (clinical form), p. 327

Standard 5.15: Pharmaceuticals Policy

Arizona Center for Minimally Invasive Surgery has policies and procedures for pharmaceuticals, including samples, which comply with existing law and which include:

a. Procurement (pharmacy, ordering of medications)

b. Storage, refrigeration and access (pharmacy, ordering of medications, storage of medications)

c. Authority to Dispense (pharmacy, medication administration)

d. Furnishing and accounting for medications (pharmacy, medication accountability)

e. Labeling with specific instructions (pharmacy, labeling medications)

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 5.0; Pharmacy; Ordering of Medications, p. 152

Section 5.0; Pharmacy; Storage and Inventory of Medications, p. 158

Section 5.0; Pharmacy; Medication Administration, p. 154

Section 5.0; Pharmacy; Medication Control and Accountability, p. 150

Section 5.0; Pharmacy; Labeling Medications, p. 169

Standard 5.16: Prescription Pads

Prescription pads are stored in a secure area, inaccessible by patients and non-authorized office staff. Prescription pads are never “pre-signed”.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 5.0; Pharmacy; Medication Control and Accountability, p. 150

Standard 5.17: Dispensing Medications

Arizona Center for Minimally Invasive Surgery does not dispense medications to patients. When prescriptions are issued to a patient, the patient has the opportunity to fill the prescription at the pharmacy of his/her choice.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 5.0; Pharmacy; Pharmacy Management, p. 145

Section 5.0; Pharmacy; Medication Administration, p. 154

Standard 5.18: Outdated Medications

Outdated medications are destroyed in compliance with policy and regulation.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 5.0; Pharmacy; Disposal of Outdated Medications, p. 174

Standard 5.19: Scheduled Medications

Scheduled drugs are logged and accounted for in a secure, double-locked area with access limited to appropriate staff.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 5.0; Pharmacy; Narcotic Accountability, p. 160



Chapter Six: Facility and Environmental Safety


Standard 6.1: Infection Control

Arizona Center for Minimally Invasive Surgery has an infection control program to identify and eliminate potential sources of infection. This program requires proper training of personnel, compliance with OSHA blood-borne pathogen requirements and includes, but is not limited to:

a. Adherence to universal precautions

b. Established procedures to limit the spread of infections among patients, health care providers and through families

c. The appropriate disposal of infectious waste and a contract with a licensed service provider organization

d. The appropriate disposal of needles and other sharp or hazardous objects

e. The appropriate sterilization of reusable medical instruments and supplies

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 7.0; Infection Control; Universal Precautions, p. 243

Section 7.0; Infection Control; Traffic Control Practices, p. 246

Section 7.0; Infection Control; Handling of Bio hazardous Waste, p. 250

Section 7.0; Infection Control; Disposal of Blades, Glass, Sharps, Needles and Syringes, p. 245

Section 7.0; Infection Control; Sterilization, p. 278

Standard 6.2: Infection Control Procedures

Arizona Center for Minimally Invasive Surgery has procedures regarding:

a. Acceptable aseptic technique

b. Resuscitative techniques

c. Care of surgical specimens

d. Handling and sterilization of reusable medical instruments and supplies

e. Routine systematic cleaning, use of cleaning agents and cleaning between surgical cases

f. he handling of infected or contaminated patients and those with communicable diseases

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Aseptic Technique, p. 98

Section 2.0; Emergency Procedures; Cardio Pulmonary Resuscitation Assignments, p. 44

Section 7.0; Infection Control; Wound Cultures and Surgical Specimens, p. 258

Section 7.0; Infection Control; Sterilization, p. 278

Section 7.0; Infection Control; Cleaning the Surgical Suite, p. 268

Section 7.0; Infection Control; Cleaning Between Cases, p. 273

Section 7.0; Infection Control; Acute or Infectious Communicable Diseases, p. 260


Standard 6.3: Operating Room Access

Access to the operating room is limited to designated personnel in proper surgical attire.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Gowns and Barrier Materials, p. 94

Standard 6.4: Infection Control Program

The infection control program includes:

a. The use of data/findings to monitor rates of post-operative and nosocomial infections

b. The use of data/findings to assess the cause of such infections

c. Taking actions based upon the findings of the assessment

d. Conducting a follow-up evaluation to determine whether the corrective course of action was successful.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 7.0; Infection Control; Infection Control Program, p. 241

Standard 6.5: Fire Inspections and Regulations

Arizona Center for Minimally Invasive Surgery submits to fire inspections as required by local fire departments and regulations.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Non-Medical Emergency Action Plan, p. 35

Standard 6.6: Exit Signs and Maps

Arizona Center for Minimally Invasive Surgery posts lighted exit signs (chevrons) and exit route maps in locations that are visible to staff and patients to ensure that patients and staff members can rapidly determine fire evacuation routes.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Non-Medical Emergency Action Plan, p. 35

Standard 6.7: Fire and Emergency/Disaster Drills

Arizona Center for Minimally Invasive Surgery conducts internal fire and emergency/disaster drills on a quarterly basis. At least two of the drills conducted annually are specific to fire emergencies.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Non-Medical Emergency Action Plan, p. 35


Standard 6.8: Fire Extinguishers

Fire extinguishers are maintained at Arizona Center for Minimally Invasive Surgery and are:

a. Visible

b. Located in an area that is convenient and accessible to all personnel

c. Serviced on a regular basis

d. Staff is trained in their use

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Non-Medical Emergency Action Plan, p. 35

Standard 6.9: Fire Safety in Oxygen Enriched Environments

The Arizona Center for Minimally Invasive Surgery operating room is an oxygen enriched environment and as such, personnel are specifically trained in fire and panic safety in the Operating Room.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Non-Medical Emergency Action Plan, p. 35

Standard 6.10: Responding to Non-Medical Emergencies

Arizona Center for Minimally Invasive Surgery has written policies and procedures in place for responding to non-medical emergencies.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Non-Medical Emergency Action Plan, p. 35

Standard 6.11: Staff Roles and Responsibilities in an Emergency

Arizona Center for Minimally Invasive Surgery has an emergency action plan that designates the roles and responsibilities of staff members in the event of a fire or other non-medical emergency. All staff are trained on the emergency action plan.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Non-Medical Emergency Action Plan, p. 35

Standard 6.12: Emergency Equipment and Medications

Emergency equipment and emergency medications are available and staff members who are ACLS-certified available to respond to an emergency.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0; Nursing Services; Staffing Patterns and Responsibilities, p. 126

Section 2.0; Emergency Procedures, Emergency Equipment, Supplies and Medications, p. 59

Section 4.0: Nursing Services; Emergency Supplies and Checklist Schedule, p. 135

Standard 6.13: Back-Up Power Source

Arizona Center for Minimally Invasive Surgery has emergency power sources with:

a. The capability to start immediately upon cessation of power.

b. The ability to power all equipment, including lighting and physiologic monitors, necessary to ensure patient safety and complete or safely terminate a procedure in progress.

c. Monthly full-load tests that are documented.

d. Evidence of scheduled maintenance.

Standard 6.14: Policies and Procedures for Responding to Medical Emergencies

Arizona Center for Minimally Invasive Surgery has written policies and procedures in place for responding to medical emergencies. These policies include a written transfer agreement with a local accredited hospital, as well as procedures for patient transport, transfer of patient records and a plan for continuity of the patient’s care upon transfer.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; Transfer Policy, p. 16

Section 2.0; Emergency Procedures; Transfer of Patient to Another Facility, p. 42

Section 2.0; Emergency Procedures; Advanced Directives, p. 65

Section 2.0; Emergency Procedures; Cardio Pulmonary Resuscitation Assignments, p. 44

Section 2.0; Emergency Procedures; Defibrillation Using External Paddles, p. 46

Section 2.0; Emergency Procedures; Unexpected Blood Loss, p. 47

Section 2.0; Emergency Procedures; Allergic Reaction, p. 49

Section 2.0; Emergency Procedures; Diagnosis and Management of Malignant Hyperthermia, p. 52

Section 2.0; Emergency Procedures; Anaphylactic Shock, p. 58

Section 2.0; Emergency Procedures; Insulin Reaction, p. 60

Section 2.0; Emergency Procedures; Laryngospasms, p. 61

Section 2.0; Emergency Procedures; Shock, p. 62

Section 2.0; Emergency Procedures; Respiratory Distress, p. 63

Standard 6.15: Staff Member Roles in an Emergency:

In the event of a medical emergency, Arizona Center for Minimally Invasive Surgery staff members are aware of their roles and responsibilities.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; General Employment Policy, p. 28


Standard 6.16: Incapacitated Surgeon Policy written by Anesthesia Provider

Arizona Center for Minimally Invasive Surgery has a written plan for the safe management of the patient in the event that the physician or anesthesia provider becomes incapacitated during the procedure.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Incapacitated Surgeon, p. 54

Section 6.0; Anesthesia; Incapacity of Anesthesia Provider, p. 227

Standard 6.17: Maintenance and Operation of Equipment

All medical, surgical and anesthesia equipment used by Arizona Center for Minimally Invasive Surgery is:

a. Properly maintained

b. Operated by appropriate and qualified personnel

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0; Nursing Services; Equipment and Supplies Checklist Schedule, p. 135

Section 6.0; Anesthesia; Care of Equipment and Materials, p. 231

Section 8.0: Materials Management; Care of Surgical Instruments, p. 297

Standard 6.18: Radiology and Imaging Equipment

Arizona Center for Minimally Invasive Surgery does not own or operate any radiology or imaging equipment.

Standard 6.19: Age Appropriate Equipment

Arizona Center for Minimally Invasive Surgery does not treat pediatric patients. All equipment used at Arizona Center for Minimally Invasive Surgery is appropriate for the treatment of adults.

Standard 6.20: Clean Facility

Arizona Center for Minimally Invasive Surgery is cleaned, well maintained and free of potential hazards that might lead to physical injury of patient or staff members.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0; Nursing Services; Cleaning Duties of the Nursing Staff, p. 130

Standard 6.21: Waiting Area

Arizona Center for Minimally Invasive Surgery provides sufficient seating in the patient waiting area to accommodate anticipated patient flow including family members.

Standard 6.22: Privacy for Health Encounters

Arizona Center for Minimally Invasive Surgery provides visual and auditory privacy for all health encounters. Consultations and medical appointments are conducted in private rooms behind closed doors. Surgeries and medical procedures are performed in the operating room where access is limited to appropriate designated personnel.

Standard 6.23: Patient Examination Rooms

Arizona Center for Minimally Invasive Surgery provides a sufficient number of patient examination rooms.

Standard 6.24: Restrooms for Disabled Persons

Arizona Center for Minimally Invasive Surgery provides restrooms that are accessible to those with disabilities.

Standard 6.25: Facility Parking

Arizona Center for Minimally Invasive Surgery provides adequate parking to patients and is located in an area that is accessible to public transportation. Arizona Center for Minimally Invasive Surgery complies with local jurisdictions in making provisions for access to the facility by patients with physical disabilities.






Chapter Seven: Surgery, Anesthesia and Invasive Diagnostic Procedures


Standard 7.1: Types of Surgical Procedures

The types of surgical procedures performed at Arizona Center for Minimally Invasive Surgery are developed by the Medical Director in conjunction with the Governing Body. Procedures available at Arizona Center for Minimally Invasive Surgery are based on the training and experience of Arizona Center for Minimally Invasive Surgery clinicians performing the procedures and are appropriate to their scope of practice.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section1.0; Management; Governing Body, p. 10

Standard 7.2: Facility, Equipment and Medication Are Appropriate to Procedures Performed

Arizona Center for Minimally Invasive Surgery’s physical space and equipment are adequate and appropriate for the types of procedures performed in the facility.

Anesthesia will be administered to patients at Arizona Center for Minimally Invasive Surgery based on:

a. The available equipment

b. The types of procedures

c. Any limitations imposed by physical space and staff resources.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0; Nursing Services; Staffing Patterns and Responsibilities, p. 126

Standard 7.3: Anesthesia Providers

Individuals administering anesthesia at Arizona Center for Minimally Invasive Surgery are licensed, qualified and working within their scope of practice. The Governing Body defines the qualifications of such personnel and a mechanism for peer review.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 6.0; Anesthesia; Anesthesia Providers, p. 203

Standard 7.4: Anesthesia Administration

Arizona Center for Minimally Invasive Surgery policy addresses the administration of anesthesia and includes:

a. Assignment of a risk category for each patient receiving anesthesia

b. Evaluation of each patient’s risk category prior to their receiving anesthesia, to be done by the licensed practitioner whose scope of practice permits

c. Documentation that the pre-anesthesia assessment and discussion of risks with the patient is done prior to a scheduled procedure.

Each Arizona Center for Minimally Invasive Surgical patient is evaluated by a physician on the day of surgery to determine whether there has been any change from his/her previous medical condition. Immediately prior to anesthesia induction, the anesthesia provider examines the patient and discusses the risk of anesthesia. This evaluation is documented in the medical record.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 6.0; Anesthesia; Anesthesia Preoperative Procedures, p. 215

Section 6.0: Anesthesia; Patient Selection Criteria, p. 219

Standard 7.5: Anesthesia Consent

All Arizona Center for Minimally Invasive Surgery patients undergoing anesthesia must sign the Arizona Center for Minimally Invasive Surgery Informed Consent for Anesthesia. The original consent form is maintained in the medical record and a copy is provided to the patient.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 6.0; Anesthesia; Consent for Anesthesia, p. 217

Appendix L: Informed Consent for Anesthesia (clinical form), p. 328

Standard 7.6: Appropriate Number of Health Care Providers

Arizona Center for Minimally Invasive Surgery requires that two healthcare workers be present during all procedures, at least one of who is a licensed physician or a licensed healthcare professional with certification in Advanced Cardiac Life Support (ACLS).

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Surgical Staffing, p. 72

Standard 7.7: Physiologic Monitoring During Anesthesia Procedures

Arizona Center for Minimally Invasive Surgery Policies and Procedures require physiologic monitoring during any procedure where anesthesia is used. Regular periodic assessment of the patient’s vital signs is performed with the interval based on the patient’s underlying health condition and the nature of the procedure. The assessment is performed by a clinician functioning within the permitted scope of practice. Only a physician, Registered Nurse, CRNA or PA can make and report assessments of a patient to the physician or surgeon performing the procedure.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 6.0; Anesthesia; Monitoring Patients Receiving Anesthesia, p. 207

Section 6.0: Anesthesia; Anesthesia Preoperative Procedures, p.215

Section 6.0 Anesthesia; Anesthesia Guidelines, p. 205


Standard 7.8: Surgery Rooms

Arizona Center for Minimally Invasive Surgical rooms are of sufficient size and are appropriately equipped for the types of procedures performed. The surgery rooms were designed taking into account the physical safety of patients and staff and meet all established standards for infection control.

Standard 7.9: Building and Fire Codes

The Arizona Center for Minimally Invasive Surgery is constructed and equipped to meet state and local building and fire codes.

Standard 7.10: Non-Flammable Anesthetic Agents

Only non-flammable anesthetic agents are present in the operating room.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 6.0; Anesthesia; Anesthesia Safety, p. 210

Standard 7.11: Licensed Personnel on Site

Until all patients are discharged from Arizona Center for Minimally Invasive Surgery, there will be at least two staff members on site at all times, one of whom is a licensed physician or a licensed health care professional with certification in Advanced Cardiac Life Support.

The Arizona Center for Minimally Invasive Surgery recovery room staff always includes:

a. A physician or one ACLS-certified person, such as an RN, when a patient is being recovered.

b. Another staff member on premises to provide assistance in the case of an emergency.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0; Nursing Services; Staffing Patterns and Responsibilities, p. 126

Section 4.0: Nursing Services; Surgical Services, Surgical Staffing, p. 72

Standard 7.12: Recovery Room Evaluation of Patient

All patients are evaluated as they enter the Arizona Center for Minimally Invasive Surgery recovery room. Based on the level of anesthesia and the needs of the patient, physiologic monitoring will be continue into the post-operative period. Monitoring assessment may include the following:

a. Blood pressure,

b. Pulse and respiratory

c. Continuous pulse oximetry

d. Continuous electro-cardiogram monitoring when indicated

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 6.0; Anesthesia; Post-Operative Anesthesia Care, p. 208

Standard 7.13: Recovery Room Staffing

The Arizona Center for Minimally Invasive Surgery recovery room is staffed by an adequate number of trained, qualified personnel, consisting of at least one licensed nurse for every two patients.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 4.0; Nursing Services; Staffing Patterns and Responsibilities, p. 126

Standard 7.14: Physical Space and Equipment

There is ample physical space and equipment for the safe recovery of every patient.

Standard 7.15: Criteria for Discharge

Arizona Center for Minimally Invasive Surgery has written criteria for discharge. However, before any patient is discharged physically from the recovery room area, the surgeon and/or anesthesia provider shall make the final determination of the appropriateness in planning the discharge. This is not made over the phone or without the physicians making a true face-to-face medical assessment for the discharge order then to be written and followed by the nursing staff.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Discharge Criteria, p. 103

Standard 7.16: Discharge Evaluation

All surgical patients are evaluated prior to leaving Arizona Center for Minimally Invasive Surgery, as follows:

a. The surgeon or anesthesia provider, as required by the Medicare Regulations, conducts the evaluation. {Updated July 2009}

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Discharge of the Surgical Patient, p. 101


Standard 7.17: Physician Availability

The physician or anesthesia provider who performed the procedure is immediately available until the patient has been discharged from Arizona Center for Minimally Invasive Surgery.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Discharge of the Surgical Patient, p. 101

Standard 7.18: Responsible Caregiver

All patients who receive anesthesia, other than local, will only be discharged from Arizona Center for Minimally Invasive Surgery when in the company and care of a responsible adult for a minimum of 24 hours, unless exempt by a physician’s order.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Discharge of the Surgical Patient, p. 101

Section 3.0; Surgical Services; Discharge Criteria, p. 103

Standard 7.19: Post-Operative Instructions

Arizona Center for Minimally Invasive Surgery patients receive clear, appropriate verbal and written post-operative instructions, including:

a. How to obtain 24-hour assistance

b. When to return for follow-up care

All Post-Operative Instructions are given and communicated with the patient prior to any anesthesia, whether via PO or IV.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Discharge of the Surgical Patient, p. 101

Section 3.0; Surgical Services; Discharge Criteria, p. 103

Appendix F: Post-Operative Care for Micro-Body Contouring (clinical form), p. 322

Appendix N: Post-Operative Instructions for Anesthesia (clinical form), P. 330

Appendix E: Outpatient Responsibility and Caregiver Instructions (clinical form), p. 321

Standard 7.20: Continuity of Care through Recovery Period

The physician who performs surgery on a patient at Arizona Center for Minimally Invasive Surgery is responsibility to continue patient care through the post-surgical recovery period. In rare cases when the original physician is unavailable to continue care, arrangements are made for that care to be continued by another Arizona Center for Minimally Invasive Surgery physician.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Ongoing Post-Operative Care, p. 104


Standard 7.21: Fluoroscopic Practitioners

Arizona Center for Minimally Invasive Surgery practitioners do not use any Fluoroscopic type of technology or surgical equipment. Only fluoroscopy is used for our specific procedures, and the State Radiological Branch for diagnostic fluoroscopic use with C-Arms authorizes our use of this fluoroscopy.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Use of Fluoro, p. 82

Standard 7.22: Proctoring for Use of Fluoroscopy

Arizona Center for Minimally Invasive Surgery physicians and Registered Nurses/Technicians performing services that use fluoroscopic technology are trained and proctored by appropriately qualified physicians and have state approved certificates of their competencies in the personnel files as well as being posted in the lobby of the center.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Use of Fluoroscopy, p. 82

Standard 7.23: Patient Evaluation for Fluoroscopy

An appropriate practitioner before treatment to determine if they qualify for Fluoroscopy evaluates patients.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Use of Fluoroscopy, p. 82

Standard 7.24: Informed Consent for Fluoroscopy

All patients receiving Fluoroscopy of any level or duration at Arizona Center for Minimally Invasive Surgery must sign an Informed Consent that is specific to the dose and duration being used, the procedure being performed and potential complications. Manufacturer information on the Fluoroscopic device is available to be provided to the patient upon request.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Use of Fluoroscopy, p. 82

Standard 7.25: Fluoroscopy Performance Standards

Each Fluoroscopic used at Arizona Center for Minimally Invasive Surgery meets FDA Mandatory Performance Standards that are specific to that device.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Use of Fluoroscopy, p. 82

Standard 7.26: Fluoroscopic Policy and Procedures

To ensure the safety of patients and staff, Fluoroscopic use at Arizona Center for Minimally Invasive Surgery is governed by Policy and Procedures that include:

a. Prominent signage that states that Fluoroscopy is in use

b. Protection of chest cavity, reproductive regions for all people exposed to the Fluoroscopy

c. Utilization of cones, shields to control the targets region of the body habitus.

d. Compliance with State and local environmental regulations and recommendations for the use of Fluoroscopy

e. Documentation logs of all inspection and maintenance of equipment

f. Operation of the Fluoroscopic and other equipment within the guidelines of the manufacturer

g. Precautions against chemical and fire hazards

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Use of Fluoroscopy, p. 82

Section 3.0; Surgical Services; Fluoroscopic Eye Protection, p. 83

Section 3.0; Surgical Services; Fluoroscopic Use and Fires Safety, p. 84

Section 3.0; Surgical Services; Smoke Evacuator, Mask and Glove Use During Fluoroscopic Procedures, p. 85

Standard 7.27: Mechanisms for Fluoroscopic Safety

Arizona Center for Minimally Invasive Surgery employs smoke evacuators, appropriate devices to control tissue debris and high filtration masks to minimize Fluoroscopic plume inhalation.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Use of Fluoroscopy, p. 82

Section 3.0; Surgical Services; Smoke Evacuator, Mask and Glove Use During Fluoroscopic Procedures, p. 85

Standard 7.28: Laboratory and Pathology Services

Arizona Center for Minimally Invasive Surgery does not perform laboratory or pathology services, with the exception of certain tests that are deemed as having been granted waived status by CLIA. Arizona Center for Minimally Invasive Surgery refers patients to external clinical laboratories for additional testing as deemed necessary by the physician and based on the procedures being performed. While the patient is free to have their laboratory testing conducted at a site of their choosing, the laboratory must be accredited and approved by CLIA and Medicare.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Laboratory Monitoring, p.79


Standard 7.29: Biological Specimens

Arizona Center for Minimally Invasive Surgery does not perform services that require the collection or analysis of biological specimens.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Laboratory Monitoring, p.79

Standard 7.30: Blood and Blood Products

No procedures performed at Arizona Center for Minimally Invasive Surgery warrant or require access to blood and blood products. Pre-surgical indication for blood or blood products would eliminate the patient from being a candidate for the surgery center. A referral to the nearest acute care hospital would be made and the patient followed there by the surgeon would be the appropriate action.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 3.0; Surgical Services; Laboratory Monitoring, p.79

Standard 7.31: Access to Acute Care

Arizona Center for Minimally Invasive Surgery takes seriously our ethical obligation to protect the life and safety of every patient. To proactively manage unexpected outcomes and ensure patient safety, Arizona Center for Minimally Invasive Surgery:

a. Allows surgery to be performed at Arizona Center for Minimally Invasive Surgery only by licensed practitioners who have admitting privileges at a local accredited or licensed acute care hospital.

b. Has a detailed procedural plan for handling medical emergencies and the transfer and admission of patients to an acute care facility when necessary.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; Transfer Policy, p.16

Standard 7.32: Transfer Hospital Peer Review

All Arizona Center for Minimally Invasive Surgery physicians agree to cooperate with the hospital’s medical staff peer review process involving the transfer of any patient to that hospital.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; Transfer Policy, p.16


Standard 7.33: Patient Transfer Following Inappropriate Care

In the event of a patient transfer to a hospital, if the hospital’s medical staff determines that inappropriate care was delivered by Arizona Center for Minimally Invasive Surgery, all of the following will be met:

a. The hospital will report these findings in a confidential communication to all the following agencies:

· AAAASF

· CMS

· DHS

· MEDICAL BOARD OF ARIZONA (or appropriate licensing agency)

b. Arizona Center for Minimally Invasive Surgery will perform a thorough peer review of the incident and take appropriate corrective action

c. If the hospital imposes any restrictions on the physician’s privilege status at the hospital, Arizona Center for Minimally Invasive Surgery will immediately report this to AAAASF, Medical Board, DHS, and then to CMS. We will also re-validate the accuracy of the NPDB by ensuring this information is communicated to the data bank, as required by federal law.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; Transfer Policy, p.16

Appendix O: Transfer Agreement

Standard 7.34: Death of a Patient

The Arizona Center for Minimally Invasive Surgery physician will file a written report with the Medical Board of Arizona within seven days of the occurrence of a death of a patient. We will also notify the accrediting body, the DHS, and the Medicare entities.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 2.0; Emergency Procedures; Death, p.64

Standard 7.35: Transfer Resulting in Prolonged Hospitalization

If Arizona Center for Minimally Invasive Surgery transfers a patient to a hospital or emergency center for medical treatment that exceeds 24 hours, the Arizona Center for Minimally Invasive Surgery physician will file a report with the Office of Statewide Health Planning and Development within 15 days.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; Transfer Policy, p.16


Standard 7.36: Additional Reports to AAAASF

Arizona Center for Minimally Invasive Surgery will report to AAAASF within 15 days of any transfer to a hospital or emergency center for treatment that exceeds 24 hours, any subsequent admission to the hospital and any occurrence of a death within seven days of a procedure performed at Arizona Center for Minimally Invasive Surgery.

Arizona Center for Minimally Invasive Surgery Ambulatory Care Manual

Section 1.0; Management; Transfer Policy, p.16

Section 2.0; Emergency Procedures; Death, p.64

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medinformation 4 years ago

Great info! Thanks for keeping everyone informed about surgical standard procedures. This is something that should be honored and never taken lightly.

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