Accreditation Council for Surgical Quality | Download Manual

Program Requirements



T he ACSQ program manual details the physical resources, human resources, clinical standards, credentialing of surgeons, data reporting standards and verification/approval processes for the Accreditation Council for Surgical Quality (ACSQ) Accreditation Program.

Purpose

The purpose of the Accreditation Council for Surgical Quality (ACSQ) Accreditation Program is to evaluate an organization's practices to determine compliance with current applicable ACSQ Standards. Our standards are in place in order to uphold the integrity of surgical quality worldwide.

Who must be accredited?

Accreditation is a requirement for all ACSQ Program Members. A new Program Member must complete the Initial Accreditation - Conditional Application before continuing with the Full Accreditation - Unconditional Application.

Eligibility

Physicians and affiliated hospitals accredited as ACSQ Center of Excellence® must undergo a process of evaluation designed to ensure the presence of a comprehensive program requirements for providing a safe surgical environment with excellent short- and long-term clinical outcomes. The evaluation process evaluates processes, i.e., equipment, supplies, training of physicians and staff and the availability of consultant services with specific emphasis on quality outcomes.

• The facility must be in business for a minimum of 6 months prior to filing a Initial Accreditation - Conditional Application

• The facility must submit the 'Locations Table'. If multiple sites, additional fees may be require

Expectations

• The prospective facility must meet the eligibility requirements with no exceptions. • All standards are addressed in facility's policies, processes and procedures (PPPs) • PPPs are followed as written

Timeframe

• The Initial Accreditation process usually takes a minimum of 6 months to complete. Time is needed in order to carry out a full, detailed analysis of the proposed facility in order to ensure the facility complies with ACSQ standards.

Process

A Initial Assessment - Conditional Accreditation Application must be submitted to initiate the accreditation process. Initial Assessment - Conditional Accreditation Application are reviewed by the ACSQ Review Committee (ARC). Based upon the information provided by the applicant, centers and physicians may obtain one of the following designations:

Approved. Applicants who are approved may apply for Full Approval within two years

Denied. Applicants who have been denied may correct their deficiencies and reapply after 6 months. Applicants may request that the application be reviewed again, or may appeal the decision to the Board of Directors

Review Status. Applicants under review status are designated when case volumes provided by an applicant are insufficient to maintain the required cases per year (institution) or lifetime experience within the two-year Conditional Status period. Applicants are neither approved nor denied but instead are asked to report their volumes at 6 months for re-evaluation

Pending Status. Applicants with Pending Status are awaiting additional information as requested by the ARC for further determination

Conditional Status participants may apply for Full Approval once a determination has been made that the applicant has the experience necessary to provide a safe and effective environment and delivery of care based upon a comprehensive and independent review of their outcomes. Once the Full Approval application is received, a site inspection is conducted. Information collected during both the site inspection and from the Full Approval application is evaluated by the ARC.

*The ACSQ Board of Directors may change or modify the processes, standards and stipulations set forth in this document as new knowledge, new technology and experience require.