The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

• A time-out is performed before the procedure.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
• The clinical record contains information that reflects the patient's care, treatment, or services.
• The organization collects data to monitor its performance.
• The organization collects information to monitor conditions in the environment.
• The organization conducts fire drills.
• The organization engages in planning activities prior to developing its Emergency Management Plan. Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
• The organization evaluates the effectiveness of its Emergency Management Plan.
• The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
• The organization implements infection prevention and control activities.
• The organization inspects, tests, and maintains medical gas and vacuum systems. Note 1: This standard does not require organizations to have the medical gas and vacuum systems discussed below. However, if an organization has these types of systems, then the following inspection, testing, and maintenance requirements apply. Note 2: Piped medical gas systems include oxygen, nitrous oxide, medical air, carbon dioxide, helium, nitrogen, instrument air and mixtures thereof. Piped vacuum systems include both medical-surgical vacuum and waste anesthetic gas disposal (WAGD) systems.
• The organization maintains fire safety equipment and fire safety building features. Note: This standard does not require organizations to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The organization maintains records for waived testing.
• The organization maintains the integrity of the means of egress. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization manages risks associated with its utility systems.
• The organization provides and maintains equipment for extinguishing fires. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization provides and maintains fire alarm systems. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
• The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
• The organization safely manages emergency medications.
• The organization safely stores medications.
• The organization uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

• A time-out is performed before the procedure.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
• The clinical record contains information that reflects the patient's care, treatment, or services.
• The organization collects data to monitor its performance.
• The organization collects information to monitor conditions in the environment.
• The organization conducts fire drills.
• The organization engages in planning activities prior to developing its Emergency Management Plan. Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
• The organization evaluates the effectiveness of its Emergency Management Plan.
• The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
• The organization implements infection prevention and control activities.
• The organization inspects, tests, and maintains medical gas and vacuum systems. Note 1: This standard does not require organizations to have the medical gas and vacuum systems discussed below. However, if an organization has these types of systems, then the following inspection, testing, and maintenance requirements apply. Note 2: Piped medical gas systems include oxygen, nitrous oxide, medical air, carbon dioxide, helium, nitrogen, instrument air and mixtures thereof. Piped vacuum systems include both medical-surgical vacuum and waste anesthetic gas disposal (WAGD) systems.
• The organization maintains fire safety equipment and fire safety building features. Note: This standard does not require organizations to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The organization maintains records for waived testing.
• The organization maintains the integrity of the means of egress. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization manages risks associated with its utility systems.
• The organization provides and maintains equipment for extinguishing fires. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization provides and maintains fire alarm systems. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
• The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
• The organization safely manages emergency medications.
• The organization safely stores medications.
• The organization uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.