Accreditation agencies estimate that more than three-fourths of all freestanding ambulatory surgery centers and an even greater proportion of office-based surgical suites are not accredited. If yours is one of them, you may be wondering Should we or shouldn't we? While the ultimate answer will differ for every facility, here are a few points to ponder as you make your decision.

THE PROS
1. It makes your care better and safer. Some doubt the ability of surveyors to see and understand all the problems in a surgery facility and bring them to your attention, but there can be no doubt that having a trained third party examine your operation will improve it in some way. The process may result in better emergency preparedness, more effective infection control procedures, superior fire safety and even better business practices. In effect, say accreditation proponents, something good will happen as a result of the process. "I would highly recommend it," says Trevor Neal, a Michigan podiatrist who underwent the process for his office-based facility. "I sleep better knowing that if an emergency were to occur, we have systems in place to handle it."

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2. It improves 'esprit de corps'. Lawrence D. Pinkner, MD, president of the SurgiCenter of Baltimore, and Jerry Henderson, CASC, executive director of the SurgiCenter, say they are reaping an unexpected benefit from the accreditation process. One year before their most recent survey, they took the accreditation manual and assigned every standard to a staff member. "Staffers had to determine whether our center met those standards. For example, one staffer had to examine 'How do we ensure patients' rights?' It was this person's responsibility to explain to the group how we met that standard," says Ms. Henderson. The exercise forced the staff to meet many times during the year to report to each other and, as a result, everyone learned things about the other parts of the organization. For example, says Ms. Henderson, the clinically-oriented nurses learned a great deal about the policies and procedures for the business office. "We have a great sense of internal pride because we all know patients are getting good care," she says.

3. It keeps you competitive. All else being equal, some insurers still prefer facilities that are accredited, since it spares them from validating on their own that a facility is safe for its customers. Ms. Henderson notes that accreditation also puts independent ASCs on an even footing with hospital outpatient facilities. "We are competing against hospitals for outpatient cases," she says, "and hospitals are all accredited." It also gives surgeons a sense of comfort and helps ensure they will want to perform surgery at your facility. "We have physicians with offices elsewhere who perform surgery here. Accreditation gives us a high-quality reputation," says Dr. Pinkner.

4. It's a fast way for a new center to get Medicare reimbursement. "It's difficult to get a Medicare survey; they have waiting lists," says Ms. Henderson. "If you can get deemed status through accreditation, you can get it done faster." JCAHO, AAAHC and AAAASF are all "deemed status" accreditors, which means they can certify ASCs for Medicare participation. This obviates the need to undergo separate, periodic surveys by state health agencies, although the entire combined survey must be unannounced when you're going for deemed status due to Medicare requirements.

5. For plastic surgeons with office-based surgery facilities, it's virtually required. The American Society of Plastic Surgeons and American Society of Aesthetic Plastic Surgeons mandate accreditation for their members' office-based surgery facilities. And if you live in a state that is tightening restrictions on office-based surgery practices of all kinds, preparing for accreditation now may help ensure a smooth-running future.

6. It helps you keep up to date with government directives and other standards. The process can and will help you comply with compliance programs (which ensure ethical business practices), HIPAA patient privacy regulations and OSHA requirements such as the Needlestick Safety Act. "It forces a center to make sure it is up to date on all appropriate standards necessary to render quality patient care," says Andrea Hyatt, CASC, administrator with the Dulaney Eye Institute in Towson, Md.

THE CONS
1. It's costly. A three-year accreditation costs from $2,025 for small office-based surgical suites to $11,800 or more for large ASCs. Most experts also recommend hiring a consultant for the first survey or two. Consultants can charge from $1,000 to $1,500 a day, bringing the face value of accreditation to $15,000 to $20,000 for most ASCs. "This big expense can deter some smaller centers," says Ms. Hyatt, whose seven-year-old center handles more than 5,000 cases per year, is state-licensed and Medicare-certified, and is only now embarking on the accreditation process. Ms. Hyatt warns that it's also important to add in hidden costs - namely, the hundreds of man-hours you and your staff will have to spend to prepare for your survey, and then comply with the standards on an ongoing basis. Some standards, for example, include:

• Setting up and maintaining a peer review process, which can be complicated for a small center in a competitive area.
• Instituting a QA program. For the AAAHC-accredited SurgiCenter of Baltimore, this required monthly 1-hour meetings with at least two physicians and three to five nurses.
• Updating old charts, a task that involves physicians.

2. There's always a chance of failure. All three major ambulatory accrediting bodies say they make every attempt to work with their customers and cite low absolute failure rates. AAAASF says 3 percent of its applicants fail; AAAHC says 1 percent fail. Nevertheless, fewer outpatient facilities actually achieve the full three-year accreditation, and this means a substantial amount of ongoing work and additional 're-survey' fees. For example, AAAHC offers one-year accreditation for facilities in "partial compliance" and six-month deferral for some other facilities, and JCAHO offers a "conditional" accreditation with "requirements for approval"-all of which may require a follow-up 're-survey'. Finally, adds Dr. Pinkner, facility managers and physicians that don't believe in accreditation in the first place stand a greater chance for failure. "If the principals feel they may fail anyway, they should ask themselves if it makes sense to proceed," he advises.

3. It's a hassle. Ms. Hyatt says the application process alone has taken two employees and considerable time. "It takes a lot of discipline to complete the application process when you are already dedicating every minute of the day to providing quality, cost-effective patient care," she notes. Other 'hassles' may include:

• Surgeon resistance. "Some doctors go to the ASC to escape the regulatory burden at the hospital and gain more control over their destiny," says Dr. Pinkner. "Now, here comes an agency instructing them how to manage their facilities." Doctors cannot divorce themselves from the process, as they often have to update charts and even change the way they practice. Many don't like using safety sharps, for example, and Ms. Henderson cites another change in the standards to come this year: New precautions for wrong-site surgery.
• Staff pressures. Because of the workload and a fear of failure, accreditation creates stress on the staff. "Staff members are walking on eggshells for weeks or even months" just before survey time, says Dr. Pinkner.
• Frustration. Although many standards are non-prescriptive, they still require centers to do things they would not otherwise do, says Dr. Pinkner. Ms. Henderson adds that all centers must meet the same standards, no matter how small: "Whether you're in solo practice or have 180 physicians, you have to go through the same machinations."

4. It's no longer necessary for reimbursement by all private insurers. "In the past, insurance companies wouldn't contract with centers that weren't accredited," says Ms. Hyatt. "Now, we find carriers are willing to contract with a center that is only Medicare-accredited, although they will demand a site survey in the absence of accreditation." According to Ms. Hyatt, these annual surveys are typically less thorough than accreditation surveys. These surveyors, who are RNs, generally review a center's policies and procedures, quality improvement and risk management programs, credentialing procedures, medical records and physical environment.

5. Accreditation may be duplicative. Ms. Henderson names New York and New Jersey as states where "you may have already met the accreditation standards by meeting the state standards." When it comes to office-based accreditation, adds Mark Pepper, a Nashville, Tennessee-based CRNA who provides anesthesia services to offices, state licensure may even be more comprehensive. For instance, he says, accreditation inspectors may not enforce the same requirements as the state fire marshall, like ensuring that the bulk supply of compressed oxygen is stored away from the actual anesthetizing location.

An imperfect world
No one says that accreditation is a panacea for what may ail a surgical facility. "Accreditation should be a minimum standard by which we practice," says Mr. Pepper. Yet, those who have undergone the process say it can definitely help you provide better care. "The biggest benefit is protection of the patient," says Ms. Henderson. Even Ms. Hyatt, who plans to submit her application soon, anticipates a "great learning experience," and says the only negatives are "time and money."