SB 396 (Hill) becomes effective on January 1, 2016, adding new patient protection measures to the current regulation of ambulatory surgery centers (“ASCs”).
First, SB 396 authorizes accreditation organizations to perform unannounced inspections after the initial accreditation inspection. Current law requires the accreditation organization to inspect ASCs at least every three years and permits the Medical Board to inspect ASCs as often as the Board deems necessary to ensure quality of care. The current law also permits inspections to investigate violations of accreditation standards or California law.
Now, under SB 396, accreditation organizations may conduct unannounced inspections at any time. Accrediting bodies must give ASCs notice that the inspection will occur within 60 days. (Although SB 396 permits unannounced inspections, it does not require unannounced inspections.)
Second, SB 396 requires every licensed person who performs procedures in an ASC to undergo a peer review at least every two years. While existing law requires members of an ASC’s medical staff to be professionally qualified and appropriately credentialed, the new peer review requirement adds an additional quality assurance measure. Peer reviews must be conducted by physicians with similar qualifications and experience as the subject of the review. Peer review findings must be reported to the ASC’s governing body, which then determines whether the subject is still qualified and appropriately credentialed to perform procedures at the ASC.
Third, all ASCs, whether accredited or not, must access the Medical Board’s License Verification System before granting or renewing an individual’s staff privileges to determine whether an “805 report” has been made. This report, made pursuant to Business & Professions Code Section 805, indicates whether the applicant has been denied staff privileges, been removed from a medical staff, or had staff privileges restricted. Accreditation organizations will be checking for compliance with this requirement in their surveys of ASCs.
As the effective date of SB 396 approaches, ambulatory surgery centers may want to kick off the New Year with a review of their medical staff bylaws, credentialing and peer review procedures and timelines, in addition to being ready for new and unannounced inspections.