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The Ambulatory Care Review Program accredits:
  • Ambulatory surgery centers (Medicare deemed status)
  • Endoscopy centers
  • Fertility clinics
  • Medical groups
  • Managed care organizations
  • Office-based surgery practices
  • OMS/dental practices
  • Pain management centers
  • Student health centers
  • Urgent care centers
  • Women’s health centers

Ambulatory and Surgery Center Accreditation Program including Medicare Deemed Status

Doctor, guy in suit, woman in suit, & blonde woman looking at laptop

Physicians often seek accreditation for their facilities to demonstrate to their patients and communities their commitment to quality and patient safety. Many facilities seek accreditation voluntarily; others are required to do so to meet state, professional society, or association requirements.

IMQ’s Ambulatory Program accredits a wide range of facilities (see side bar). The program offers facilities a practical, meaningful, and cost-effective method for ensuring quality health care and achieving accreditation as well as Medicare deemed status to participate in the Medicare program. IMQ is recognized by authorities in a number of states and has expanded its programs to include facilities around the country.

IMQ offers educational consultation and assistance during the on-site survey and throughout the entire accreditation process.

The accreditation process has three steps:

Prior to applying for a facility accreditation, it is important to review the latest IMQ standards, found in the Ambulatory Accreditation Manual. This will help you assess your readiness for accreditation and the work that may be involved in preparing your facility.

To reduce the amount of time required on-site, and therefore the cost of the survey, it is recommended that each facility submit specific documents with their application prior to the survey. These documents are listed in the instruction section of the Application (pdf).

To facilitate the survey process, your facility will receive a pre-survey analysis. Upon receipt of your application  and supporting documents (listed in the instruction section of the application), IMQ reviews and evaluates your submission for compliance with our standards. IMQ provides written feedback to you prior to the survey date, allowing you the opportunity to make any necessary revisions before your on-site survey begins.

The survey fee is determined based the scope of services identified on your application.

An IMQ survey generally lasts one to three days, depending on your facility’s size and the types of procedures performed. A one-day survey usually begins at 8:00 AM with a brief meeting and a tour of the facility. The surveyor interviews key personnel, observes a procedure, and validates during the course of the day that the practice of the facility follows the policies and procedures submitted. Some documentation, such as credential files, meeting minutes, and peer review records, will be reviewed on site on the survey day. A final meeting at the end of the day gives the surveyor an opportunity to present findings for discussion and clarification. Because the surveyor’s role is to record and report findings to the accreditation committee, no decision is given by the surveyor on site.

The survey focuses on seven major areas:

  • Administration: scope of services, patient rights, and administrative policies and procedures
  • Personnel: staff policies and procedures, physician credentialing in both small group settings and larger settings with an organized medical staff
  • Quality management and peer review
  • Medical Records: surgery and invasive diagnostic records, HIPAA and clinical record confidentiality
  • Care and treatment
  • Facility and environmental safety: infection control, fire safety, preparation for emergencies, medical equipment, and facility design and access
  • Surgical, anesthesia, and invasive diagnostics

Accreditation decisions are made by IMQ’s Ambulatory Care Review Committee (ACRC), comprised of physicians, Registered Nurses, and Administrative surveyors. An accreditation decision is usually rendered within three weeks of the survey.  For Medicare deemed status, decisions are rendered within ten business days of the end of the survey.  Accreditation periods are for three years (or nine months for a new facility that is not yet treating patients).

After the on-site survey, the surveyor(s) completes the survey report forms and other survey documents and submits the documents to IMQ for preparation. The reports and surveyor(s) recommendations are sent to the ACRC, which meets monthly. The Committee makes the final accreditation decision.

The accreditation decisions that may be rendered are:

  • Three-year accreditation (95% of standards fully met.  All standards not met will require an interim report to obtain full compliance.)
  • Three-year accreditation with one-year re-survey (less than 95% of standards met.  All standards not met will require an interim report to obtain full compliance.)
  • Nine-month provisional (for new facilities)
  • Non-accreditation
  • Deferred decision

It is IMQ’s intent to notify facilities of the decision within ten days of the ACRC meeting. The ACRC may require a written interim report providing a plan of correction to address specific issue(s) during the facility’s accreditation period.

 See Left Sidebar "Documents" for required documents

For more information, contact:
Victoria Samper, Vice President Ambulatory Accreditation
Phone: 415-882-5173