Oral & Maxillofacial Surgery Facility Standards and Checklist

Transcription

1 Oral & Maxillofacial Surgery Facility Standards and Checklist AMERICAN ASSOCIATION FOR ACCREDITATION OF AMBULATORY SURGERY FACILITIES, INC.

2 AMERICAN ASSOCIATION FOR ACCREDITATION OF AMBULATORY SURGERY FACILITIES, INC. Oral & Maxillofacial Surgery Facility Standards and Checklist for Accreditation of Ambulatory Surgery Facilities Version 2 August Revised Publication 2010 American Association for Accreditation of Ambulatory Surgery Facilities, Inc. 1

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4 TABLE OF CONTENTS Page # Facility Identification 5 Current Staff Identification 7 The AAAASF OMS Surgery Facility Accreditation Program 13 Definition of Facility Classes 17 Facility Director s Attestation 21 Oral and Maxillofacial Standards Section # 100 General Environment Procedure Room Policy, Environment and Procedures Post Anesthetic Procedure Recovery Area General Safety in the Facility IV Fluids and Medications Medical Records Quality Assessment, Quality Improvement Personnel Anesthesia 77 Answer Sheets 3

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6 AAAASF FACIILTY IDENTIFICATION FORM Washington Street P.O. Box 9500 Gurnee, IL No Information Changes Facility Identification Number Information Changes Noted Below Facility Class: CLASS A CLASS B CLASS C-M CLASS C (Check one) Name of Facility Name of Facility Director (must be M.D. or D.O.) Name of Office Manager or Head Nurse Address Suite City State Zip Phone Fax Website Name of Facility Owner, Controlling Stockholder and/or Beneficial Ownership (List additional names on separate sheet) Facility Licensure Date Not Previously Accredited by Other Accrediting Organization Previously Accredited by Other Accrediting Organization Name(s) of Other Organization: Initial Inspection Date Class Last Re- Inspection Date Class X Facility Director s Signature 5 Date

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8 AAAASF CURRENT STAFF IDENTIFICATION FORM Washington Street P.O. Box 9500 Gurnee, IL Please list all practitioners performing any procedures in the facility Name of Practitioner (Please Indicate Credentials - M.D., D.O., M.D./D.D.S., D.P.M.) State Medical License # Specialty(s) ABMS/AOABOS Certifying Board Year Certified or Year Eligible Local Accredited or Licensed Acute Care Hospital at Which Doctor Has Current Admitting Privileges Department or Section Has or has held unrestricted privileges in their specialty at an accredited or licensed acute care hospital within 30 minutes of this facility for all procedures that they perform at this facility? NO YES List Hospital(s) Name of Practitioner (Please Indicate Credentials - M.D., D.O., M.D./D.D.S., D.P.M.) State Medical License # Specialty(s) ABMS/AOABOS Certifying Board Year Certified or Year Eligible Local Accredited or Licensed Acute Care Hospital at Which Doctor Has Current Admitting Privileges Department or Section Has or has held unrestricted privileges in their specialty at an accredited or licensed acute care hospital within 30 minutes of this facility for all procedures that they perform at this facility? NO YES List Hospital(s) 7

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10 AAAASF CURRENT STAFF IDENTIFICATION FORM Washington Street P.O. Box 9500 Gurnee, IL Please list all practitioners performing any procedures in the facility Name of Practitioner (Please Indicate Credentials - M.D., D.O., M.D./D.D.S., D.P.M.) State Medical License # Specialty(s) ABMS/AOABOS Certifying Board Year Certified or Year Eligible Local Accredited or Licensed Acute Care Hospital at Which Doctor Has Current Admitting Privileges Department or Section Has or has held unrestricted privileges in their specialty at an accredited or licensed acute care hospital within 30 minutes of this facility for all procedures that they perform at this facility? NO YES List Hospital(s) Name of Practitioner (Please Indicate Credentials - M.D., D.O., M.D./D.D.S., D.P.M.) State Medical License # Specialty(s) ABMS/AOABOS Certifying Board Year Certified or Year Eligible Local Accredited or Licensed Acute Care Hospital at Which Doctor Has Current Admitting Privileges Department or Section Has or has held unrestricted privileges in their specialty at an accredited or licensed acute care hospital within 30 minutes of this facility for all procedures that they perform at this facility? NO YES List Hospital(s) 9

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12 AAAASF CURRENT STAFF IDENTIFICATION FORM Washington Street P.O. Box 9500 Gurnee, IL Please list all practitioners performing any procedures in the facility Name of Practitioner (Please Indicate Credentials - M.D., D.O., M.D./D.D.S., D.P.M.) State Medical License # Specialty(s) ABMS/AOABOS Certifying Board Year Certified or Year Eligible Local Accredited or Licensed Acute Care Hospital at Which Doctor Has Current Admitting Privileges Department or Section Has or has held unrestricted privileges in their specialty at an accredited or licensed acute care hospital within 30 minutes of this facility for all procedures that they perform at this facility? NO YES List Hospital(s) Name of Practitioner (Please Indicate Credentials - M.D., D.O., M.D./D.D.S., D.P.M.) State Medical License # Specialty(s) ABMS/AOABOS Certifying Board Year Certified or Year Eligible Local Accredited or Licensed Acute Care Hospital at Which Doctor Has Current Admitting Privileges Department or Section Has or has held unrestricted privileges in their specialty at an accredited or licensed acute care hospital within 30 minutes of this facility for all procedures that they perform at this facility? NO YES List Hospital(s) 11

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14 The AAAASF Oral & Maxillofacial Surgery Facility Accreditation Program The American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) conducts an accreditation program that verifies that a facility meets nationally recognized safety standards. The procedural facility accreditation program is conducted by physicians and nurses who determine the standards under the direction of a Board of Directors. The Oral & Maxillofacial facility accreditation is intended for ambulatory facilities performing procedures under sedation which would include oral & maxillofacial surgeons, and others. The AAAASF strives for the highest standards of excellence for its facilities by regularly revising and updating its requirements for patient safety and quality of care. Basic Mandates Patients receiving anesthetic agents other than topical or local anesthesia should be supervised in the immediate post discharge period by a responsible adult for at least hours, depending on the procedure and anesthesia used. Changes in facility ownership must be reported to the AAAASF Office within thirty (30) days of the change. Any death occurring in an accredited facility, or any death occurring within thirty (30) days of a procedure performed in an accredited facility, must be reported to the AAAASF office within five (5) business days after the facility is notified or otherwise becomes aware of that death. In addition to this notification, the death must also be reported as an unanticipated procedure sequela in the semi-annual Peer Review report. In the event of a death occurring within thirty (30) days of a procedure done in an AAAASF accredited facility, an unannounced inspection may be done by a senior inspector The facility director is responsible for establishing and enforcing policies that protect patients. The director monitors all members of the medical and facility staff for compliance with this policy. AAAASF Patient Rights should be posted, followed and promoted. All individuals using the facility must meet one of the following criteria (throughout this document the terms, medicine and medical apply to all M.D., D.M.D, D.O, and D.D.S. degrees): 1. A physician certified or eligible for certification by one of the member boards of the American Board of Medical Specialties (ABMS). 2. A Doctor of Dental Medicine or Dental Surgery certified or eligible for certification by the American Board of Oral and Maxillofacial Surgery (ABOMS). All oral and maxillofacial surgeons practicing in an AAAASF accredited facility must hold, or must demonstrate that they have held, unrestricted hospital privileges in their specialty at an accredited and/or licensed acute care hospital within thirty (30) minutes of the accredited facility for all procedures that they perform within the facility. Only procedures included in those hospital privileges may be performed within the AAAASF accredited facility. An oral and maxillofacial surgeon must be present when anesthesia other than strictly local is being administered in Class B, Class C-M or Class C accredited facilities. If pediatric patients are treated in the facility, a minimum of one staff member who is PALS certified (Pediatric Advanced Life Support Course), must be present in the facility until all pediatric patients recovering from anesthesia have met criteria for discharge from the facility. The aesthetic procedures performed by Oral & Maxillofacial surgeons that are permitted by state and federal regulations and laws, and are also performed by Board Certified Plastic Surgeons, Otolaryngologists and Dermatologists must follow the applicable standards in the AAAASF Regular Standards Manual. Failure to adhere to the basic mandates of AAAASF will result in referral to the Investigations Committee. Sanctions by the Board of Directors may result in emergency suspension and revocation. 13

15 The following list of OMS Office-Based procedures are permitted under this current version of the AAAASF Oral & Maxillofacial Facility Standards. The AAAASF Board of Directors reserves the right to review and edit these procedures at any time based upon differing scopes of practice standards, and changing state and federal regulations and laws. Dentoalveolar Extractions simple and complex Alveolectomy/Alveoplasty Periapical Surgery (Apicoectomy) Hard & Soft Tissue Grafting Harvest & Placement Local and Distant Xenograft Allograft Autograft Placement of Dental Implants Pathology Hard & Soft Tissue Biopsy and Excision Salivary Duct and Gland Odontogenic and Non-Odontogenic Lesions of the Jaws Sinus & Nose Grafting Closure of Oro-Antral and Oro-Nasal Communication Caldwell-Luc Management of Infections Hard & Soft Tissue Odontogenic TMJ Arthrocentesis and Arthroscopy Trauma Hard & Soft Tissue Trauma Lacerations Fractures Closed and Open Reduction Dental including Avulsion Pain Management head and neck Orthognathic & Esthetic Alloplastic Implants Sliding Genioplasty Removal of Hardware Esthetic procedures as delineated by State-designated Scope of Practice Addendum May 2010: And any other procedure as encompassed by the American Dental Association's definition of the specialty of Oral and Maxillofacial Surgery, subject to that which is allowed under a state's legally-defined scope of practice for either dentistry or Oral and Maxillofacial Surgery. 14

16 Onsite Inspection A facility is inspected every three years. The facility inspector will review any deficiencies with the facility director and forward the Standards and Checklist answer sheet to the AAAASF Central Office. To be accredited by AAAASF, a facility must meet every standard for its Class (A, B, C-M or C). Onsite Inspection Privacy Policy Onsite AAAASF Inspections typically involve the attention of the facility Medical Director, the anesthesia provider, and the facility staff working intently with the AAAASF surveyor(s). The inspection process must remain focused, and therefore, AAAASF has directed that equipment representatives not be present during AAAASF s announced or unannounced inspections/surveys. Accreditation consultants may be present during the surveys; however AAAASF asks that consultants remain silent during the inspection process until it is completed. All AAAASF surveyor(s) have the authority to request any participants to leave the inspection process if interference becomes a problem. AAAASF greatly appreciates the cooperation of all concerned parties by complying with this directive. Self-Evaluation Inspection A facility is evaluated by the facility director each year between inspections, and the Standards and Checklist answer sheet is sent to the AAAASF Office. A facility s AAAASF accreditation remains valid if it continues to meet every standard for its Class (A, B, C-M or C). Otherwise, accreditation is revoked. 15

17 Denial or Loss of Accreditation The AAAASF will deny or revoke accreditation of a facility if the facility fails to satisfy every standard for its Class (A, B, C-M or C), or if any Oral and Maxillofacial Surgeons performing procedures at the facility that: Has had their privileges to perform procedures restricted or limited by any hospital at which the oral and maxillofacial surgeon has privileges, related to lack of clinical competence, ethical issues, or professional problems other than economic competition. Has been found to be in violation of the Code of Ethics of any professional medical society or association of which they are a member. Has had their right to practice medicine, and/or dentistry limited, suspended, terminated or otherwise affected by any state, province, or country, or if they have been disciplined by any medical and/or dentistry licensing authority. Non-reporting of any of the above to the AAAASF. Hearing Any facility whose accreditation has been revoked or denied by the AAAASF has the right to a Hearing at which it may present information to show that it has satisfied the requirements for accreditation. The Hearing process is described in the AAAASF Bylaws, available from the AAAASF Central Office. Emergency Suspension or Emergency Probation The AAAASF may place a facility on Emergency Suspension or Emergency Probation status upon receiving information that a state medical or dental board has taken action, or begun formal proceedings which may result in it taking action against a license held by an oral & maxillofacial surgeon practicing at the facility, or the Board of Directors determining that the facility may no longer meet AAAASF standards for accreditation. A facility that has been placed on Emergency Suspension or Emergency Probation status will remain in such status pending an investigation and possible Hearing, conducted in accordance with AAAASF procedures that are available from the AAAASF Central Office. 16

18 Definition of AAAASF Facility Classes Class A: In a Class A Facility, all surgical, endoscopic and/or pain management procedures may be performed under the following anesthesia: 1. Topical Anesthesia 2. Local Anesthesia If oral medications are used, only minimal and moderate sedation levels are permitted in Class A Facilities. Class A Facilities must meet all Class A standards. Class B: In a Class B facility, all oral and maxillofacial surgical or dental procedures may be performed under the following anesthesia: 1. Topical Anesthesia 2. Local Anesthesia 3. Parenteral Sedation 4. Regional Anesthesia 5. Dissociative Drugs (excluding Propofol) Agents 3 through 5 may be administered by: - An Anesthesiologist - An appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist - A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law, or by policy adopted by the facility - An Anesthesia Assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under direct supervision of an Anesthesiologist - Registered Nurses, only under the supervision of a qualified Oral and Maxillofacial Surgeon The use of Propofol, Spinal Anesthesia, Epidural Anesthesia, Endotracheal Intubation Anesthesia, Laryngeal Mask Airway Anesthesia, and/or Inhalation General Anesthesia (including Nitrous Oxide) are prohibited in a Class B facility Class B facilities must meet all Class A and Class B standards. 17

19 Class C-M: In a Class C-M facility, all oral and maxillofacial surgical or dental procedures may be performed under the following anesthesia: 1. Topical Anesthesia 2. Local Anesthesia 3. Parenteral Sedation 4. Regional Anesthesia 5. Dissociative Drugs (including propofol) Agents 3 through 5 may be administered by: - An Anesthesiologist - An Appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist - A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law, or by policy adopted by the facility - An Anesthesia Assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under direct supervision of an Anesthesiologist - Registered Nurses, (excluding Propofol) under the supervision of a qualified Oral and Maxillofacial Surgeon Propofol anesthesia may be administered only by: - A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law, or by policy adopted by the facility - An Anesthesiologist - An appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist The use of Spinal Anesthesia, Epidural Anesthesia, Endotracheal Intubation Anesthesia, Laryngeal Mask Airway Anesthesia, and/or Inhalation General Anesthesia (including Nitrous Oxide) is prohibited in a Class C-M facility. Class C-M facilities must meet all Class A, Class B and Class C-M standards. 18

20 Class C: In a Class C facility all oral and maxillofacial surgical or dental procedures may be performed under the following anesthesia: 1. Topical Anesthesia 2. Local Anesthesia 3. Parenteral Sedation 4. Regional Anesthesia 5. Nitrous Oxide 6. Dissociative Drugs (including Propofol) 7. General Anesthesia (with or without Endotracheal Intubation or Laryngeal Mask Airway Anesthesia) Agents 3 through 5 may be administered by: - An Anesthesiologist - An Appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist - A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law, or by policy adopted by the facility - An Anesthesia Assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under direct supervision of an Anesthesiologist - Registered Nurses, (excluding Propofol) under the supervision of a qualified Oral and Maxillofacial Surgeon Propofol and agents 6 and 7 may be administered only by: - An Anesthesiologist - An appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist - A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law or by policy adopted by the facility - An Anesthesia Assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under the direct supervision of an Anesthesiologist - Class C facilities must meet all Class A, Class B, Class C-M and Class C standards. 19

21 Important Notice Maximal patient safety has always been our guiding concern. We are proud that our Standards may be considered the strongest of any agency that accredits ambulatory surgery facilities, and that many consider them to be the Gold Standard. We recognize, however, that they need to be part of a living document, and we continually re-evaluate and revise these Standards in the light of medical advances and changing legislative guidelines. The AAAASF Accreditation Program requires 100% compliance with each Standard to become and remain accredited. There are no exceptions. However, when a Standard refers to appropriate or proper or adequate, reasonable flexibility and room for individual consideration by the inspector is permitted as long as patient and staff safety remain uncompromised. Definition Adequate is meant to encompass size, space, maintenance, cleanliness, free of clutter, lighting, appropriately equipped, etc. The facility director must attest that the facility meets all local, state, and federal regulations, since such governmental regulations may supersede AAAASF Standards. Please note, however, that the stricter regulation applies, whether it is the federal, state, local, or AAAASF standard. Please complete and sign the following Facility Director s Attestation document and return it to the AAAASF office. 20

22 Facility Director s Attestation As director of the (name of facility), located at, I attest that this facility meets all applicable local, state and federal zoning, licensure and construction codes and regulations, including Certificate of Need requirements, laboratory regulations, and anesthesia permits if mandated. I further acknowledge that wherever governmental regulations or codes differ from AAAASF Standards, the stricter rule is applicable. Facility director s signature Date Print name of facility director Return this signed and completed form to: AAAASF P.O. Box 9500 (mailing address) Gurnee, IL Toll-free: Phone: Fax:

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24 The following Standards are the property of the Association For Accreditation of Ambulatory Surgery Facilities, Inc. Unauthorized use in prohibited. Copyright 2011 American Association For Accreditation of Ambulatory Surgery Facilities, Inc. All rights reserved. AAAASF P.O. Box 9500 (mailing address) Gurnee, IL Toll-free: Phone: Fax: Web: FOR THE SURVEYOR VERSION ONLY Each Standard Question Must Have a Response! If a standard for the Class (A, B, C-M or C) does not apply to the situation in this facility, indicate such by marking N/A on the answer sheet. Each numbered Standard question in this booklet must have a response. If a Standard for a facility does not apply to the situation in the facility, the inspector must indicate such by marking N/A on the answer sheet. For every N/A, there must be an explanation noted by the inspector on the answer sheet to justify that response. All NO answers should be discussed with the facility director or appropriate staff, and the inspector should make recommendations as to how the deficiencies should be corrected. 23

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26 100 BASIC MANDATES Basic Mandates Oral and Maxillofacial Standard Version Patients receiving anesthetic agents other than topical or local anesthesia should be supervised in the immediate post discharge period by a responsible adult for at least hours, depending on the procedure and anesthesia used Changes in facility ownership must be reported to the AAAASF Office within thirty (30) days of the change Any death occurring in an accredited facility, or any death occurring within thirty (30) days of a procedure performed in an accredited facility, must be reported to the AAAASF office within five (5) business days after the facility is notified or otherwise becomes aware of that death. In addition to this notification, the death must also be reported as an unanticipated procedure sequela in the semi-annual Peer Review report. In the event of a death occurring within thirty (30) days of a procedure done in an AAAASF accredited facility, an unannounced inspection may be done by a senior inspector AAAASF Patient Rights should be posted, followed and promoted All individuals using the facility must meet one of the following criteria (throughout this document the terms, medicine and medical apply to all M.D., D.M.D, D.O, and D.D.S. Degrees): 1. A physician certified or eligible for certification by one of the member boards of the American Board of Medical Specialties (ABMS). 2. A Doctor of Dental Medicine or Dental Surgery certified or eligible for certification by the American Board of Oral and Maxillofacial Surgery (ABOMS). 25

27 100 BASIC MANDATES Oral and Maxillofacial Standard Version The facility director is responsible for establishing and enforcing policies that protect patients. The director monitors all members of the medical and facility staff for compliance with this policy All oral and maxillofacial surgeons practicing in an AAAASF accredited facility must hold, or must demonstrate that they have held, unrestricted hospital privileges in their specialty at an accredited and/or licensed acute care hospital within thirty (30) minutes of the accredited facility for all procedures that they perform within the facility. Only procedures included in those hospital privileges may be performed within the AAAASF accredited facility. An oral and maxillofacial surgeon must be present when anesthesia other than strictly local is being administered in Class B, Class C-M or Class C accredited facilities Onsite AAAASF Inspections typically involve the attention of the facility Medical Director, the anesthesia provider, and the facility staff working intently with the AAAASF surveyor(s). The inspection process must remain focused, and therefore, AAAASF has directed that equipment representatives not be present during AAAASF s announced or unannounced inspections/surveys. Accreditation consultants may be present during the surveys; however AAAASF asks that consultants remain silent during the inspection process until it is completed. All AAAASF surveyor(s) have the authority to request any participants to leave the inspection process if interference becomes a problem. AAAASF greatly appreciates the cooperation of all concerned parties by complying with this directive A Class A: In a Class A Facility, all surgical, endoscopic and/or pain management procedures may be performed under the following anesthesia: 1. Topical Anesthesia 2. Local Anesthesia If oral medications are used, only minimal and moderate sedation levels are permitted in Class A Facilities. Class A Facilities must meet all Class A standards. 26

28 100 BASIC MANDATES Oral and Maxillofacial Standard Version A,B Class B: In a Class B facility, all oral and maxillofacial surgical or dental procedures may be performed under the following anesthesia: 1. Topical Anesthesia 2. Local Anesthesia 3. Parenteral Sedation 4. Regional Anesthesia 5. Dissociative Drugs (excluding Propofol) Agents 3 through 5 may be administered by: An Anesthesiologist An appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law, or by policy adopted by the facility An Anesthesia Assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under direct supervision of an Anesthesiologist Registered Nurses, only under the supervision of a qualified Oral and Maxillofacial Surgeon The use of Propofol, Spinal Anesthesia, Epidural Anesthesia, Endotracheal Intubation Anesthesia, Laryngeal Mask Airway Anesthesia, and/or Inhalation General Anesthesia (including Nitrous Oxide) are prohibited in a Class B facility Class B facilities must meet all Class A and Class B standards. 27

29 100 BASIC MANDATES Oral and Maxillofacial Standard Version A,B,C-M Class C-M: In a Class C-M facility, all oral and maxillofacial surgical or dental procedures may be performed under the following anesthesia: 1. Topical Anesthesia 2. Local Anesthesia 3. Parenteral Sedation 4. Regional Anesthesia 5. Dissociative Drugs (including propofol) Agents 3 through 5 may be administered by: An Anesthesiologist An Appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law, or by policy adopted by the facility An Anesthesia Assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under direct supervision of an Anesthesiologist Registered Nurses, (excluding Propofol) under the supervision of a qualified Oral and Maxillofacial Surgeon Propofol anesthesia may be administered only by: A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law, or by policy adopted by the facility An Anesthesiologist An appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist The use of Spinal Anesthesia, Epidural Anesthesia, Endotracheal Intubation Anesthesia, Laryngeal Mask Airway Anesthesia, and/or Inhalation General Anesthesia (including Nitrous Oxide) is prohibited in a Class C-M facility. Class C-M facilities must meet all Class A, Class B and Class C-M standards. 28

30 100 BASIC MANDATES Oral and Maxillofacial Standard Version Class C: In a Class C facility all oral and maxillofacial surgical or dental procedures may be performed under the following anesthesia: 1. Topical Anesthesia 2. Local Anesthesia 3. Parenteral Sedation 4. Regional Anesthesia 5. Nitrous Oxide 6. Dissociative Drugs (including Propofol) 7. General Anesthesia (with or without Endotracheal Intubation or Laryngeal Mask Airway Anesthesia) Agents 3 through 5 may be administered by: An Anesthesiologist An Appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law, or by policy adopted by the facility An Anesthesia Assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under direct supervision of an Anesthesiologist Registered Nurses, (excluding Propofol) under the supervision of a qualified Oral and Maxillofacial Surgeon Propofol and agents 6 and 7 may be administered only by: An Anesthesiologist An appropriately credentialed Oral and Maxillofacial Surgeon or Dental Anesthesiologist A Certified Registered Nurse Anesthetist (CRNA) under physician supervision if required by state or federal law or by policy adopted by the facility An Anesthesia Assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under the direct supervision of an Anesthesiologist Class C facilities must meet all Class A, Class B, Class C-M and Class C standards. 29

31 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES Policy A policy for a procedure pause or a time out protocol is in place and practiced prior to every procedure. This protocol should include: Pre-procedure verification process to include medical records and imaging studies to be reviewed by the procedure room team. Missing information or discrepancies must be addressed at this time. Marking the procedure site where appropriate Side/Site identification will comply with the Universal Protocol standards for oral and maxillofacial surgical and/or dental procedures. Time Out immediately before starting the procedure - Conduct a final verification by at least two (2) members of the procedure team confirming the correct patient, procedure, site marking(s) and, as applicable, special equipment or requirements. As a fail-safe measure, the procedure is not started until any and all questions or concerns are resolved Environment The facility displays a professional appearance in keeping with an Oral and Maxillofacial Surgery facility designed to carry out procedures. The facility should be neat, comfortable and clean and should include a waiting area, business office and sanitary lavatory facilities. One or more dedicated exam rooms should be available that provide for privacy and treatment in a sanitary, orderly environment There is a room dedicated for use as a procedure room A An exam room may function as a procedure room. 30

32 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES The procedure room(s) is adequately ventilated and temperature controlled There is adequate storage space to hold equipment, supplies and medications. Storage space should be adequate to minimize the need to leave the procedure room for frequently used supplies, equipment and/or medications Storage space provides easy access for identification and inventory of supplies The procedure room(s) is properly cleaned, maintained and free of litter and clutter Each procedure room is of a size adequate to allow for the presence of all equipment and personnel necessary for the performance of the procedures, and must comply with applicable local, state or federal requirements. There must be ample clear space on each side of the procedure table to accommodate emergency personnel and equipment in case of emergency, and permit the safe transfer of the patient to a gurney for transport. Facility personnel can physically demonstrate to the inspector that the emergency criteria, as stated above, can be met in the procedure room space available There are no overloaded wall plugs or extension cords in use, no altered grounding plugs in use, and wires are not broken, worn or unshielded Unauthorized individuals are deterred from entering the procedure room by locks, alarms, or facility personnel. 31

33 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES Sterile supplies are stored away from potential contamination in closed cabinets/drawers or if not, away from heavy traffic areas Sterile supplies are labeled to indicate sterility, and are packaged and sealed to prevent accidental opening Each sterilized pack is marked with the date of sterilization. When more than one autoclave is available, each pack must be labeled to identify in which autoclave it was sterilized If one sink is used both for dirty instruments and to scrub for procedures, there is a written policy to clean and disinfect the sink prior to scrubbing hands Procedures - Sterilization The facility has at least one autoclave which uses high pressure steam and heat, or all sterile items are single use disposable Gas sterilizers and automated endoscope reprocessors (AER) must be vented as per manufacturer s specifications All instruments used in patient care are sterilized, where applicable. 32

34 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES Monitoring records are retained for the sterilization or other disinfection process and should be reviewed and stored for a minimum of three (3) years A weekly spore test, or its equivalent, is performed on each autoclave and the results filed and kept for three (3) years. The sterility of each load in the autoclave is checked with indicator tape, chemical monitors, or other effective means both on the outside and inside of the pack If a spore test is positive, there is a protocol for remedial action to correct the sterilization process. 33

35 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES Asepsis Instrument handling and reprocessing areas are cleaned and maintained There is strict segregation of dirty procedure equipment and instruments that have been cleaned and are in the preparation and assembly area A written protocol is present for the reprocessing all instruments and equipment used in patient care Between cases, the procedure room(s) is cleaned with disinfectants Personal protective equipment is available for all appropriate procedures Hand hygiene is performed in accordance with current CDC guidelines The facility policy manual should include infection control policies and procedures that are consistent with current CDC guidelines. 34

36 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES Maintenance and Cleaning The entire procedure room suite is cleaned and disinfected according to an established schedule adequate to prevent cross-contamination All blood and body fluid spills are cleaned using germicides that are virucidal, bactericidal, tuberculocidal and fungicidal A written protocol has been developed for use by housekeeping personnel for cleaning of floors, tables, walls, ceilings, counters, furniture and fixtures of the procedure suite All openings to outdoor air are effectively protected against the entrance of insects, animals, etc Surfaces The floors are covered with an easily cleaned material which is smooth and free from breaks or cracks. If the floors contain seams or individual tiles, they are sealed with an impermeable sealant other than silicone Equipment A bio-medical technician annually inspects all equipment (including electrical outlets, breaker/ fuse boxes, and emergency light and power supplies) and reports in writing that the equipment is safe and operating according to the manufacturer s specifications. 35

37 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES Only inspected equipment is used in the procedure room The equipment s specifications are kept in an organized file All equipment is on a maintenance schedule with records kept for a minimum of at least three (3) years. Stickers may be placed on individual equipment; however written records must be maintained All equipment repairs and changes are done by a bio-medical technician with records kept for a minimum of three (3) years There is an adequate procedure room table or chair The procedure room is provided with adequate lighting Procedure Room Equipment List Self inflating (Ambu ) bags, if used, are capable of delivering positive pressure ventilation with oxygen. 36

38 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES A reliable source of oxygen, adequate for the length of the surgery (back up should consist of at least one full E cylinder) If a central source of piped oxygen is used, the system must meet all applicable codes Sufficient space to accommodate the necessary personnel, equipment and monitoring devices is available There is an adequate and reliable source of suction An EKG monitor with pulse read-out is present Pulse oximeters must be present in both the procedure room and recovery area if both rooms are being used simultaneously Blood pressure monitoring equipment is present. 37

39 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES A standard defibrillator, or an Automated External Defibrillator unit (AED), is present which is checked at least weekly for operability, and the test results are kept for a minimum of three (3) years Oral and nasopharyngeal airways for each size of patient treated in the facility are present Nasopharyngeal airways are present Laryngoscope is present Endotracheal tubes are present Endotracheal stylet is present C If present, mechanical ventilator should have a continuous use device which indicates a disconnect from the O2 source via an audible signal. 38

40 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES When uni-polar electrocautery is used, a single use disposable grounding pad is used Medical Hazardous Waste All medical hazardous wastes are stored in OSHA (Occupational Safety and Health Act) acceptable containers, and separated from general refuse for special collection and handling Used disposable sharp items are placed in puncture-resistant containers located close to the area in which they are used There is a written policy for cleaning of spills which may contain blood borne pathogens Emergency Power The procedure room has an emergency power source, (e.g., a generator or battery powered inverter), with capacity to operate adequate monitoring, anesthesia, procedure equipment, cautery and lighting for a minimum of thirty (30) minutes. If two of more procedure rooms are used simultaneously, an adequate emergency power source must be available for each procedure room. (OR in case of a power failure, the facility has back-up power on all monitoring equipment.) The emergency power source, including internal battery back-up, is able to begin generating ample power to operate essential electrical equipment used in the procedure room within thirty (30) seconds of a power failure. 39

41 Oral and Maxillofacial Standard Version PROCEDURE ROOM POLICY, ENVIRONMENT AND PROCEDURES The emergency power equipment is checked monthly to insure proper function, and the test results are filed and kept for a period of three (3) years. 40

42 Oral and Maxillofacial Standard Version POST-ANESTHETIC PROCEDURE RECOVERY AREA Post-Anesthetic Recovery Area There is an adequate recovery area within the procedure suite The recovery area is equipped and readily accessible to handle emergencies All recovering patients must be observed and supervised by an anesthesiologist, a dental anesthesiologist, or a CRNA, or an Oral and Maxillofacial Surgeon, or an R.N. in the recovery area A separate pulse oximeter is available for each patient in the recovery area There is a recovery record that includes vital signs, sensorium, medications and nurse s notes The procedure room may be used for patient recovery if only one procedure is scheduled that day, or if the recovering patient meets all discharge criteria prior to beginning the next procedure, or if there is another procedure room available for the next procedure. 41

43 Oral and Maxillofacial Standard Version POST-ANESTHETIC PROCEDURE RECOVERY AREA Patients transferred to the post-anesthetic recovery area are accompanied by a member of the anesthesia team who is knowledgeable about the patient Patients transferred to the post-anesthetic recovery area will be continually evaluated and monitored as needed during transport Evaluation in the recovery area following an anesthetic procedure will include: Documentation of patient s time of arrival Assessment of the patient by the anesthesia recovery staff, as well as by a responsible oral and maxillofacial surgeon Transmission of a verbal report on the patient to the recovery staff from a member of the anesthesia team who accompanies the patient Transfer of information concerning the pre-procedure condition of the patient and the procedure anesthesia course. 42

44 Oral and Maxillofacial Standard Version POST-ANESTHETIC PROCEDURE RECOVERY AREA A member of the anesthesia team remains in the post-anesthesia area until the post-anesthesia care nurse accepts responsibility for the patient A minimum of one ACLS certified staff member must be present in the facility until all patients recovering from anesthesia have met criteria for discharge from the facility. 43

45 Oral and Maxillofacial Standard Version POST-ANESTHETIC PROCEDURE RECOVERY AREA Discharge from the post-anesthetic procedure recovery area There is a written policy that whenever parenteral sedation, dissociative drugs, epidural, spinal or general anesthesia is administered, and an oral & maxillofacial surgeon is immediately available until the patient is discharged from the recovery area Approved and standardized discharge criteria are used An oral & maxillofacial surgeon determines that the patient meets discharge criteria based upon input from the post-anesthetic procedure recovery staff. That oral and maxillofacial surgeon name must be noted on the record Written instructions, including procedures for emergency situations, are given to an adult who is responsible for the patient s care and transportation following a procedure Unless a patient is having only local anesthesia, they must be discharged from the facility in the company of a responsible adult Personnel assist with discharge from the recovery area. 44

46 Oral and Maxillofacial Standard Version POST-ANESTHETIC PROCEDURE RECOVERY AREA Procedure Room Equipment List C An anesthesia machine is required if volatile agents or nitrous oxide are available in the facility. If total intravenous anesthesia (TIVA), spinal or epidural anesthesia is used exclusively, and no inhalation agents (volatile or nitrous oxide) are available, an anesthesia machine is not required Sufficient electrical outlets are available, labeled and grounded to suit the location (e.g.; wet locations, cystoscopy-arthroscopy) and connected to emergency power supplies where appropriate Adequate illumination for patients, machines and monitoring equipment, which can include battery powered illuminating systems Emergency cart is available with defibrillator, necessary drugs and other CPR equipment Quality of Care A licensed or qualified anesthesia provider supervising or providing care in the facility should participate in quality assurance and risk management in the facility The oral and maxillofacial surgeon and the anesthesia provider should concur on the appropriateness of procedures performed at the facility. This is based on the medical status of the patients and qualifications of providers and facility resources. 45

47 Oral and Maxillofacial Standard Version POST-ANESTHETIC PROCEDURE RECOVERY AREA A patient who, by reason of pre-existing or other medical conditions, is at significant risk for outpatient procedure in this facility should be referred to alternative facilities. 46

48 Oral and Maxillofacial Standard Version GENERAL SAFETY IN THE FACILITY General AAAASF is committed to establishing guidelines to provide safe and effective outpatient procedure care. The Facility must comply with all applicable Occupational Safety and Health Administration (OSHA), Centers for Disease Control and Prevention (CDC), National Fire Protection Association (NFPA), federal, state and local codes and regulations. The facility must comply with the stricter regulation (whether it is the AAAASF Standard or local, state, or federal law) There is a facility safety manual Facility safety manual contains all applicable requirements of OSHA Facility safety manual is in accordance with other federal and state regulations Facility safety manual provides employees with information about hazardous chemicals used and methods to minimize hazards to personnel There is a written exposure control plan which is reviewed and updated at least annually There is a written chemical hazard communication program which is reviewed and updated annually. 47

49 Oral and Maxillofacial Standard Version GENERAL SAFETY IN THE FACILITY If a laser is used, safety measures are taken to protect patients and staff from injury If x-ray equipment is used, safety measures are taken to protect patients and staff from injury Warnings and signs exist to warn patients and staff when x-ray or laser equipment is in use Staff maintains dosimetry badges and records, if applicable, for at least three (3) years Facility must be compliant with guidelines listed in the CDC Standard Precautions for cross-contamination of syringes, multi-use and single use vials. (Refer to CDC Preventing Transmission of Infectious Agents in Healthcare Settings 2007) Emergency Protocols There is a written protocol for: Security emergencies, such as an intruder in the facility, an unruly patient or visitor, a threat to the staff or patients Fires and fire drills. 48

50 Oral and Maxillofacial Standard Version GENERAL SAFETY IN THE FACILITY Return to the procedure room for patient emergencies Cardiopulmonary resuscitation A situation in which the oral and maxillofacial surgeon becomes incapacitated A situation in which the person administering anesthesia becomes incapacitated Response to power failure emergencies Transferring patients in an emergency Plan for emergency evacuation of the facility. 49

51 Oral and Maxillofacial Standard Version GENERAL SAFETY IN THE FACILITY Transfer Agreement There is a written transfer agreement with a local accredited or licensed acute care hospital within thirty (30) minutes driving time, or the oral and maxillofacial surgeon has privileges to admit patients to such a hospital Hazardous Agents All explosive and combustible materials are stored and handled in a safe manner according to state, local and/or National Fire Protection Association (NFPA) codes Compressed gas cylinders are stored and handled according to state, local and/or National Fire Protection Association (NFPA) codes Hazardous chemicals are labeled as hazardous Fire Controls The facility is equipped with heat sensors and/or smoke detectors An adequate number of fire extinguishers are available. 50

52 Oral and Maxillofacial Standard Version GENERAL SAFETY IN THE FACILITY Fire extinguishers are inspected annually and conform to local fire codes Exits Fire exit signs are posted and illuminated consistent with state, local and/or the NFPA codes and OSHA codes There are sufficient emergency lights for exit routes and patient care areas in case of power failure Hallways, stairways and elevators are sufficiently wide to allow emergency evacuation of a patient by emergency personnel and their equipment If requested, the facility s personnel can demonstrate safe evacuation of a patient. 51

53 500 IV FLUIDS AND MEDICATIONS Intravenous Fluids Oral and Maxillofacial Standard Version Intravenous fluids such as Lactated Ringer s solution and normal saline are available in the facility Medications Emergency medications are readily available and procedure room personnel know their location There is a dated narcotic inventory and control record which includes the use of narcotics on individual patients. Such records must be kept in the form of a sequentially numbered bound journal from which pages may not be removed, or in a tamper-proof and secured computer record, consistent with state and federal law. A loose leaf or spiral bound notebook does not fulfill this regulation The inventory of narcotics is verified by two licensed members of the procedure room team at least weekly, and on any day that narcotics are administered, and according to state regulations All narcotics and controlled substances are secured and locked under supervised access Outdated medications are removed. 52

54 500 IV FLUIDS AND MEDICATIONS ACLS Algorithm Oral and Maxillofacial Standard Version A complete copy of the current ACLS Algorithm must be available on the emergency cart The following medications must be available in the facility at all times as required by current ACLS Algorithms: Epinephrine Lidocaine plain Vasopressors, other than epinephrine (example Ephedrine ) Narcotic antagonist (e.g. Narcan ) Seizure arresting medication (e.g. a benzodiazephine; example Midazolam ) 53

55 500 IV FLUIDS AND MEDICATIONS Oral and Maxillofacial Standard Version Bronchospasm arresting medication (e.g. inhaled beta agonist; example Albuterol ) Intravenous corticosteroids (example Dexamethasone ) Other drugs: IV Antihistamines (example Diphenhydramine ) Short-acting beta-blocker (example Esmolol or Labetalol ) C Neuromuscular blocking agents including non-depolarizing agents such as rocuronium or depolarizing agents such as succinylcholine Benzodiazephine reversing agent (e.g. Mazicon, Flumaz, Cenil ) Atropine 54

56 500 IV FLUIDS AND MEDICATIONS Malignant Hyperthermia Oral and Maxillofacial Standard Version The current and complete MHAUS malignant hyperthermia algorithm must be available on the emergency cart. If potential malignant hyperthermia triggering agents such as isoflurene, servofluane, and desflurane, and the depolarizing muscle relaxant succinylcholine are ever used, or are present in the facility, the following requirements apply: C There must be adequate screening for MH risk that includes but is not limited to a family history of unexpected death(s) following general anesthesia or exercise; a family or personal history of MH, a muscle or neuromuscular disorder, high temperature following exercise; a personal history of muscle spasm, dark or chocolate colored urine, or unanticipated fever immediately following anesthesia or serious exercise C The facility director and all operating surgeons and anesthesiology providers should be aware of genetic and/or CHCT (Caffeine-Halothane Contracture Testing) for MH and refer patients for appropriate testing if there is a suspicious history as above prior to permitting surgery to take place in the facility C The medical director should be able to demonstrate that all operating surgeons and anesthesia providers have familiarity with the early recognition of impending MH crisis as defined by MHAUS C The medical director will insure that all staff is trained and annual drills are conducted for MH crisis and management including actual dilution of at least one vial of actual Dantrolene (expired OK). Staff should be assigned roles prior to drills and a written protocol outlining those personnel and their roles is on file. Documentation of drills is required C A minimum of 1000 ML (IV bag or similar container) of preservative- free H2) diluents for Dantrolene 55

57 500 IV FLUIDS AND MEDICATIONS Oral and Maxillofacial Standard Version C A minimum of four (4) 50cc ampoules of NaHCO C A minimum of twelve (12) vials of Dantrolene C An additional 24 vials of Dantrolene and diluents are stored in the facility, or the facility has a written agreement of another source that will provide those 24 vials of Dantrolene and diluents on a STAT basis within 15 minutes C The MHAUS Malignant Hyperthermia Algorithms must be available on the emergency cart C Flow sheets for any MH intervention as well as forms to rapidly communicate progress of intervention with receiving facilities are on the emergency cart and all ASC's must document and report any "adverse metabolic or musculoskeletal reaction to anesthesia". This documentation must be transportable with the patient when transferred to receiving facility C Facilities should establish the best destination as a transfer standard, which means the facility director would preplan for MH transfer and establish the capabilities of a facility within a reasonable distance. E.g. a tertiary care center that is further away may be better than a community type ER which is closer. Arrangements must be made in advance with EMS system if that is to be activated. Ability of receiving transport team to continue MHAUS protocol must be ensured in advance as well as by the medical director. 56

58 600 MEDICAL RECORDS General Oral and Maxillofacial Standard Version Medical records must be legible, documented and completed accurately Medical records must be retained the number of years as required by state and/or federal law; or a minimum of three (3) years to comply with the AAAASF three year inspection cycle Medical records are filed for easy accessibility, and must be maintained in the procedural facility regardless of the location of the physician s office Medical records must be kept secure and confidential, consistent with HIPAA regulations Medical clearance should be recorded, if applicable. A current history and focused/pertinent physical examination by the oral and maxillofacial surgeon, anesthesia provider, or the patient s personal physician is recorded within two weeks of procedures on all patients for major procedures, and for those patients for minor procedures who require a physical exam. The medical record must contain a current medical history taken on the same day as the procedure, and recorded by the physician or anesthesia provider prior to the administration of anesthesia. Oral and maxillofacial surgeons may do the history and physical examination if permitted by state and federal regulations The history and physical examination should cover the organs and systems commensurate with the procedure(s). 57

59 600 MEDICAL RECORDS Oral and Maxillofacial Standard Version Drug allergies/sensitivities Current medications Previous serious illness Current and chronic illness Previous surgery Bleeding tendencies Treating oral and maxillofacial surgeon or consultants are contacted in cases where the history and physical examination warrant Appropriate laboratory procedures are performed where indicated. 58

60 600 MEDICAL RECORDS Informed Consent Forms Oral and Maxillofacial Standard Version An informed consent is always obtained which authorizes the oral and maxillofacial surgeon by name to perform the procedure(s) and describes the procedure(s) Expectations, alternatives, risks and complications are discussed with the patient, and these are documented The informed consent provides consent for administration of anesthesia or sedatives under the direction of an oral and maxillofacial surgeon, CRNA, Anesthesiologist or Dental Anesthesiologist Laboratory, Pathology, X-Ray, Consultation and Treating Physician Reports Printed or written copies of these reports are kept in the medical record All laboratory results must be reviewed by the registered nurse or oral and maxillofacial surgeon. All abnormal results must be reviewed and initialed by the oral and maxillofacial surgeon within one (1) week of receipt of results All other reports, such as pathology reports and medical clearance reports, must be reviewed and initialed by the oral and maxillofacial surgeon. 59

61 600 MEDICAL RECORDS Oral and Maxillofacial Standard Version Outside clinical laboratory procedures must be performed by a licensed and accredited facility The name of the pathologist must be on all pathology reports. 60

62 Oral and Maxillofacial Standard Version MEDICAL RECORDS Procedure Room Records (Major Cases) A procedure log must include: A separate procedure log of major cases is maintained, either in a hard copy bound log with sequentially numbered pages, or in a secured computer log. Procedures done solely under local anesthesia are not required to be recorded in this log Sequential numerical listing of patients either consecutive numbering from the first case carried out in the facility or consecutive numbers starting each year Date of procedure Patient s name and/or identification number Procedure(s) The oral and maxillofacial surgeon(s) name Type of anesthesia. 61

63 600 MEDICAL RECORDS Oral and Maxillofacial Standard Version Name of person(s) administering anesthesia Name of person(s) assisting oral and maxillofacial surgeon(s) (M.D., D.O., Dentist, or oral and maxillofacial surgeon, registered nurse, scrub tech/circulating registered nurse, dental assistant, physician s assistant, anesthesia assistant, or other qualified personnel A separate anesthesia record is maintained which: Vital signs are recorded during procedures All medications given to a patient are recorded including date, time, amount and route of administration All intravenous and subcutaneous fluids given pre-procedurally, intra-procedurally, and post-procedurally are recorded Post-procedure vital signs are recorded until the patient is discharged from the facility. 62

64 600 MEDICAL RECORDS Oral and Maxillofacial Standard Version There is a procedure report which includes procedure technique and findings Post-procedure progress notes are recorded. 63

65 Oral and Maxillofacial Standard Version QUALITY ASSESSMENT/QUALITY IMPROVEMENT Quality Improvement The facility has a written quality improvement program in place which should include surveys or projects which: Monitor and evaluate patient care Evaluate methods to improve patient care Identify and correct deficiencies within the facility Alert the Medical Director to identify and resolve problems Peer Review Note: To be HIPAA compliant, a copy of the Business Associates Agreement must be signed by each oral and maxillofacial surgeon participating in Peer Review, and a copy retained on file in the facility. For an example of a generic HIPAA Business Associates Agreement, contact the AAAASF Central Office. 64

66 Oral and Maxillofacial Standard Version QUALITY ASSESSMENT/QUALITY IMPROVEMENT Peer review is performed at least every six (6) months (biannually) and includes reviews of both random cases and unanticipated sequelae using the AAAASF forms and reporting format. Peer Review must be reported on line at or submitted to AAAASF in hard copy for AAAASF staff to manually enter on line for an additional processing fee. A random sample of the cases for each oral and maxillofacial surgeon must include the first case done by each oral and maxillofacial surgeon each month during the reporting period for a total of six (6) cases. If an oral and maxillofacial surgeon using the facility has done less than six (6) cases during a reporting period, all of that oral and maxillofacial surgeon s cases during that period must be reviewed If peer review sources external to the facility are used to evaluate delivery of medical care, the Business Associates Agreement is so written as to waive confidentiality of the medical records Peer review may be done by a recognized peer review organization or an oral and maxillofacial surgeon, other than the oral and maxillofacial surgeon doing the procedure Random Case Review A minimum of six (6) cases per oral and maxillofacial surgeon utilizing the facility, or 2% of all cases in a group practice are reviewed every six months Random case reviews must include at a minimum: Adequacy and legibility of history and physical exam. 65

67 Oral and Maxillofacial Standard Version QUALITY ASSESSMENT/QUALITY IMPROVEMENT Adequacy of consent Presence of laboratory, EKG and radiographic reports Presence of a written procedure report Anesthesia and recovery record (with IV sedation or general anesthesia) Presence of instructions for post-procedure care Documentation of complications Unanticipated Procedure Sequelae All unanticipated procedure sequelae which occur within thirty (30) days of procedures are reviewed, including but not limited to: 66

68 Oral and Maxillofacial Standard Version QUALITY ASSESSMENT/QUALITY IMPROVEMENT Unplanned hospital admission Unscheduled return to the procedure room for a complication of a procedure Significant and/or unexpected complications such as severe infection, bleeding, or injury to other body structure Cardiac or respiratory problems during stay at facility or within forty eight (48) hours of discharge Allergic reactions Patient or family complaint Equipment malfunction leading to injury or potential injury to patient Death occurring within thirty (30) days of a procedure done in the facility. 67

69 Oral and Maxillofacial Standard Version QUALITY ASSESSMENT/QUALITY IMPROVEMENT Identification of the problem Immediate treatment or disposition of the case Outcome Reason for problem Assessment of efficacy of treatment Patient Rights The Patient Rights document is prominently displayed, or a copy is provided to each patient. The Patient Rights document is also adhered to by facility personnel. 68

70 Oral and Maxillofacial Standard Version PERSONNEL The Medical Director must have an M.D., D.M.D., or D.D.S. degree The medical director must be a maxillofacial surgeon currently licensed by the state in which the facility is located The medical director must be an oral and maxillofacial surgeon certified or eligible for certification by either an American Board of Medical Specialties (ABMS medical specialty certifying boards), or the American Board of Oral and Maxillofacial Surgery (ABOMS) The medical director must be actively involved in the direction and management of the facility Staff Physicians Oral and maxillofacial surgeon(s) using the facility are credentialed and qualified for the procedures they perform Oral and maxillofacial surgeon(s) using the facility have core privileges in their specialty at a licensed acute care hospital. 69

71 Oral and Maxillofacial Standard Version PERSONNEL Oral and maxillofacial surgeon(s) who perform procedures in facilities accredited by AAAASF must hold or demonstrate that they have held valid, unrestricted hospital privileges in their specialty at an accredited and/or licensed hospital. Only procedures included within those hospital privileges may be performed within the AAAASF accredited facility. If the privilege-granting hospital does not possess equipment or technology to allow an oral and maxillofacial surgeon to be credentialed for a specific procedure, the oral and maxillofacial surgeon may provide alternative evidence of training and competence in that procedure. Individual consideration will be given if the oral and maxillofacial surgeon no longer possesses or cannot obtain such privileges, and can demonstrate that loss of, or inability to obtain such privileges was not related to lack of clinical competence, ethical issues, or problems other than economic competition If the oral and maxillofacial surgeon does not hold admitting privileges at a hospital within 30 minutes driving time, there must be a signed and dated document from a person in the same specialty who has admitting privileges in a hospital within 30 minutes driving time from the facility that indicates their willingness to admit the patient to the hospital All individuals using the facility must meet one of the following criteria: 1. A Doctor of Medicine certified or eligible for certification by one of the member boards of the American Board of Medical Specialties. (ABMS) 2. A Doctor of Dental Medicine or Doctor of Dental Surgery certified or eligible for certification by the American Board of Oral and Maxillofacial Surgery (ABOMS). ABMS and/or ABOMS certified or eligible medical and/or dental specialists who perform procedures within the accredited facility may perform only those procedures delineated in their ABMS and/or ABOMS board certification and/or covered by AMA Core Principle #7. AOA certified or eligible physicians who perform procedures within the accredited facility may perform only those procedures delineated in their AOA Board Certification and/or covered by AMA Core Principle #7. The AMA Core Principle #7 (from AMA Resolution dated April, 2003): AMA Core Principal #7 - Physicians performing office-based procedures must be currently board certified/qualified by one of the boards recognized by the American Board of Medical Specialties, American Osteopathic Association Bureau of Osteopathic Specialists, or a board with equivalent standards approved by the state medical board. The procedure must be one that is generally recognized by that certifying board as falling within the scope of training and practice of the physician providing the care. 70

72 Oral and Maxillofacial Standard Version PERSONNEL Each oral and maxillofacial surgeon must currently be licensed by the state in which they practice. A copy of each oral & maxillofacial surgeon s current license must be maintained on file in the facility Any change in the oral and maxillofacial surgeon s staff must be reported in writing to the AAAASF Central Office within thirty days of such changes. Copies of the credentials of any new staff, including their current medical license, ABMS Board Certification, ABOMS Board Certification, letter of eligibility or equivalent documentation, and current documentation of hospital privileges or satisfactory explanation for the lack thereof must also be sent to the AAAASF Central Office Any action affecting the current professional license of the facility director, a member of the medical staff, a member of the oral and maxillofacial surgeon and staff or other licensed facility staff must reported in writing to the AAAASF Central Office within ten days of the time the facility director becomes aware of such action Anesthesiologist/CRNA If anesthesiologists and/or CRNA s participate in patient care at the facility, they are qualified for the procedures they perform and their credentials have been verified Must be licensed or accredited by the state in which they practice C-M,C Must be responsible for the administration of dissociative anesthesia with propofol, spinal or epidural blocks, or general anesthesia and monitoring of all life support systems. 71

73 Oral and Maxillofacial Standard Version PERSONNEL Ensure that all anesthesia equipment is in proper working order Cannot function in any other capacity (e.g., procedure assistant or circulating nurse) during the procedure, except for oral and maxillofacial surgery where the operator/anesthetist model has been established utilizing a two-person team for Moderate sedation and a three person team for Deep sedation. All personnel must abide by all state and federal regulations and laws governing the administration of anesthesia Pain management procedures in the facility are performed only by a board certified or a board eligible anesthesiologist, and/or an appropriately credentialed oral and maxillofacial surgeon for head and neck pain management Procedure Room Personnel All procedure suite personnel are under the immediate supervision of an oral and maxillofacial surgeon, registered nurse or an oral and maxillofacial surgeon s anesthesia assistant Must meet acceptable standards as defined by their professional governing bodies, where applicable This person is responsible for the operation of the procedure room suite and patient care areas. 72

74 Oral and Maxillofacial Standard Version PERSONNEL Personnel Records IMPORTANT: Employee information must remain strictly confidential. Individual or personal information such as previous employment, health information (except state required immunization and tests), disabilities, performance reviews and employment are protected and of no interest to the AAAASF inspector. However, the inspector does need to confirm that an adequate file is kept on each employee relating to the items listed below. Please have only this data available for each employee, separate from employee files. Personnel records should contain the following: There is a manual outlining personnel policies The manual contains personnel policies and records which are maintained according to OSHA and ADA guidelines Any health problems of the individual which may be hazardous to the employee, other employees or patients, and a plan of action or special precautions delineated as needed Resume of training and experience Current certification or license if required by the state. 73

75 Oral and Maxillofacial Standard Version PERSONNEL Date of employment Description of duties Record of continuing education Inoculations or refusals Personnel records document training in the following: Hazard safety training Blood borne pathogens Universal precautions. 74

76 Oral and Maxillofacial Standard Version PERSONNEL Other safety training such as the operation of a fire extinguisher At least Basic Cardiopulmonary Life Support (BCLS) certification, but preferably Advanced Cardiac Life Support (ACLS) for each procedure room and recovery team member Knowledge, Skill & CME Training The procedure room personnel have knowledge to treat cardiopulmonary and anaphylactic emergencies. At least one member of the procedure room team, preferably the physician or the anesthesia care giver, holds current ACLS certification The procedure room personnel are familiar with equipment and procedures utilized in the treatment of the above emergencies If a gas sterilizer is used, personnel are thoroughly familiar with the operating instructions Personnel Safety If a gas sterilizer is used, appropriate personnel are badge tested to insure that there is no significant ethylene oxide exposure. 75

77 Oral and Maxillofacial Standard Version PERSONNEL C Personnel are properly trained in the control procedures and work practices that have been demonstrated to reduce occupational exposures to anesthetic gases There is a written policy for what is considered to be personal protective equipment for specific tasks in the facility (e.g., instrument cleaning, disposal of biological waste, procedures, etc.). 76

78 Oral and Maxillofacial Standard Version ANESTHESIA Delivery of Anesthesia Registered nurses may administer agents 3 and 5 (except for propofol) under the supervision of a qualified oral and maxillofacial surgeon. Propofol anesthesia may be administered only by a CRNA or an anesthesiologist, or an appropriately credentialed oral and maxillofacial surgeon or dental anesthesiologist All anesthetics other than topical or local anesthetic agents are delivered by either an anesthesiologist, an appropriately credentialed oral and maxillofacial surgeon or dental anesthesiologist, or by a CRNA (under physician supervision if required by state or federal law or by a policy adopted by the facility), or by an anesthesiology assistant (as certified by the National Commission for the Certification of Anesthesiologist Assistants) under direct supervision of an anesthesiologist. All personnel must abide by all state and federal regulations and laws governing the administration of anesthesia. Parenteral sedation, other than propofol, may be administered by a registered nurse under the direct supervision of a qualified oral and maxillofacial surgeon. By the end of 2013, to qualify for AAAASF accreditation, all Anesthesia Assistants must be certified by the AAOMS Anesthesia Assistant Program The oral and maxillofacial surgeon responsible for supervising the administration of anesthesia must have knowledge of anesthetics and resuscitative techniques. The following anesthesia standards apply to all patients who receive anesthesia or sedation/analgesia. In extreme emergencies or life-threatening circumstances, these standards may be modified, and all such circumstances should be documented in the patient s record Pre-Anesthesia Care If children are operated upon in the facility, there should be a written policy defining the unique and periprocedure care of pediatric patients. This is based upon considerations of age, risk categories, procedure, and facility equipment and capability. 77

79 Oral and Maxillofacial Standard Version ANESTHESIA Written policy for pediatric patients is available and current An oral & maxillofacial surgeon is responsible for determining the medical status of the patient and must examine the patient immediately before procedures and must: Verify that an anesthesia care plan has been developed and documented Verify that the patient or a responsible adult has been informed about the anesthesia care plan An oral & maxillofacial surgeon must be present when any anesthetic agent, other than topical or local anesthesia, is administered. The anesthesia care plan is based on: A review of the medical record Medical history. 78

80 Oral and Maxillofacial Standard Version ANESTHESIA Prior anesthetic experiences Drug therapies Medical examination and assessment of any conditions that might affect the pre-procedure risk A review of the medical tests and consultations A determination of pre-procedure medications needed for anesthesia Providing pre-procedure instructions Anesthetic Monitoring If responsible for supervising anesthesia or providing anesthesia, the qualified oral and maxillofacial surgeon must be present in the procedure suite throughout the anesthetic. 79

81 Oral and Maxillofacial Standard Version ANESTHESIA C Patient monitoring during anesthesia will consist of: Oxygenation Assessment by O2 analyzer. If an anesthesia machine is used during general anesthesia, the anesthesia machine has an alarm for low O2 concentration B,C Pulse oximetry Circulation may be monitored by one or several of the following: Continuous EKG during procedures Blood pressure Heart rate every five (5) minutes (minimum) B,C Pulse oximetry C-M,C Heart auscultation. 80

82 Oral and Maxillofacial Standard Version ANESTHESIA C-M,C Temperature should be monitored when clinically significant changes in body temperature are expected Transfers/Emergencies Anesthesia personnel should review and be familiar with the facility s emergency protocol for cardiopulmonary emergencies and other internal and external disasters Anesthesia personnel should be trained and knowledgeable about the facility s protocols for safe and timely transfer of a patient to an alternative care facility when extended or emergency services are required. 81

83 Please fill out the attached score sheets as part of your 2nd Year or 3rd Year Self Survey. Once completed, fill in the Facility ID and Facility name. Also, have the Director fill in his name, sign, and date. Note that you will be responsible for any updates to the Standards during your 2nd and 3rd Year Self Surveys. Facility ID Facility Name Director (print) Director (signature) Date 1

84 Oral and Maxillofacial Standard Version Basic Mandates Policy Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Environment Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Procedures - Sterilization Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Asepsis Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Maintenance and Cleaning Compliant Deficient N/A Compliant Deficient N/A 2

85 Oral and Maxillofacial Standard Version Compliant Deficient N/A Compliant Deficient N/A Surfaces Compliant Deficient N/A Equipment Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Procedure Room Equipment List Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Medical Hazardous Waste Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Emergency Power Compliant Deficient N/A 3

86 Oral and Maxillofacial Standard Version Post-Anesthetic Recovery Area General Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Evaluation in the recovery area following an anesthetic procedure will include: Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Discharge from the post-anesthetic procedure recovery area Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Procedure Room Equipment List Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Quality of Care Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Emergency Protocols Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Transfer Agreement Compliant Deficient N/A Hazardous Agents Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Fire Controls Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Exits Compliant Deficient N/A Compliant Deficient N/A 4

87 Compliant Deficient N/A Compliant Deficient N/A Oral and Maxillofacial Standard Version Intravenous Fluids Compliant Deficient N/A Medications Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A ACLS Algorithm Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Other drugs: Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Malignant Hyperthermia Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A 5

88 Compliant Deficient N/A Compliant Deficient N/A Oral and Maxillofacial Standard Version General Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Informed Consent Forms Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Laboratory, Pathology, X-Ray, Consultation and Treating Physician Reports Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Procedure Room Records (Major Cases) Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A 6

89 Compliant Deficient N/A Compliant Deficient N/A Oral and Maxillofacial Standard Version Quality Improvement Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Peer Review Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Random Case Review Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Unanticipated Procedure Sequelae Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A 7

90 Compliant Deficient N/A Patient Rights Compliant Deficient N/A Oral and Maxillofacial Standard Version The Medical Director must have an M.D., D.M.D., or D.D.S. degree Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Staff Physicians Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Anesthesiologist/CRNA Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Procedure Room Personnel Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Personnel Records Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A 8

91 Personnel records document training in the following: Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Knowledge, Skill & CME Training Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Personnel Safety Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Oral and Maxillofacial Standard Version Delivery of Anesthesia Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Pre-Anesthesia Care Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Anesthetic Monitoring Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Circulation may be monitored by one or several of the following: Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Compliant Deficient N/A Transfers/Emergencies Compliant Deficient N/A Compliant Deficient N/A 9

92 ! THE AMERICAN ASSOCIATION FOR ACCREDITATION OF AMBULATORY SURGERY FACILITIES, INC. AAAASF OFFICE MAILING ADDRESS: P.O.BOX 9500 GURNEE, IL TOLL-FREE: PHONE: FAX: