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Office-Based Surgery Accreditation Fact Sheet

The Office-Based Surgery (OBS) Accreditation Program was introduced in 2001. The OBS Accreditation Program serves as a quality oversight tool for smaller, office-based surgical practices located in a business occupancy.

Benefits of Accreditation

  • Nationally acknowledged benchmark of quality.
  • Demonstrates a commitment to the highest level of patient safety and patient care.
  • Assists with recognition from insurers, associations, and other third parties.
  • Provides a competitive advantage.
  • Helps organize and strengthen performance improvement efforts.
  • Helps office-based surgery practices become high reliability organizations.
  • Provides constructive educational opportunities.
  • Offers valuable insights and educational tips from experienced surveyors.
  • Enhances alignment with Joint Commission accredited organizations throughout the continuum of care. 

Eligibility

To be eligible for OBS accreditation, the organization or practice must meet these criteria:

  • The organization is in the United States or its territories or, if outside the United States, is operated by the U.S. government or under a charter of the U.S. Congress.
  • If required by law, the organization or practice has a license or registration to conduct its scope of services. The organization can demonstrate that it continually assesses and improves the quality of its care, treatment and/or services. This process includes a review by clinicians, including those knowledgeable in the type of care, treatment and/or services provided at the organization.
  • The organization or practice identifies the services it provides, indicating which care, treatment and/or services it provides directly, under contract or through some other arrangement.
  • The organization or practice provides services that can be evaluated by The Joint Commission’s standards.
  • The test, treatments or interventions provided at the organization are prescribed or ordered by a licensed independent practitioner in accordance with state and federal requirements.
  • The organization or practice meets parameters for the minimum number of patients/volume of services required for organizations seeking Joint Commission initial accreditation or reaccreditation; that is, three patients served, with at least one patient having a procedure at the time of survey.
  • The organization or practice is limited to business occupancy, which is defined as an occupancy that can only have three or fewer individuals at the same time, who are either rendered incapable of self-preservation in an emergency or are undergoing general anesthesia.
  • The organization or practice must be surgeon-owned or surgeon-operated (for example, a professional services corporation, private physician office or small group practice).
  • The organization provides invasive procedures to patients. Local anesthesia, minimal sedation, conscious sedation or general anesthesia are administered. (Includes laser eye surgery using topical anesthesia; excluded are practices that limit procedures to excisions of skin lesions, moles, and warts and abscess drainage limited to the skin and subcutaneous tissue.)

Organizations or practices seeking Medicare certification through The Joint Commission (deemed status surveys) or pursuing advanced diagnostic imaging (ADI) recognition must be surveyed under the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC).

Standards

The OBS standards, which can be found in E-dition, are a customized subset of The Joint Commission’s ambulatory care standards, maintaining the integrity of the ambulatory care accreditation process and ensuring the highest level of patient care and safety. The Joint Commission develops its standards in consultation with healthcare experts, professionals, and researchers, as well as purchasers and consumers.

Accreditation Process

The Joint Commission’s accreditation process concentrates on operational systems critical to the safety and quality of patient care. To earn and maintain accreditation, an office-based surgery practice must undergo an on-site survey every three years. A typical OBS survey lasts one day. The objective of the survey is not only to evaluate the practice but also to provide education and guidance that will help staff continue to improve performance. Surveyors for the OBS accreditation program are healthcare professionals from the ambulatory care field who have knowledge, training and experience in smaller surgery settings.

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