Case Study:
Physician-Owned Outpatient Surgery Center

Full Accreditation achieved within 7 Months during COVID-19 pandemic amid staffing vacancies, limited resources, low patient demand and a pending sale of the facility

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Case Study Breakdown

Despite significant staffing challenges and within a seven-month period, Spectrum Health Partners (SHP) Principal Cindy Segar-Miller successfully prepared for and led the outpatient surgery center through a rigorous accreditation review that resulted in full accreditation of the facility.

SHP Services Delivered

  • Project Management
  • Facility Optimization for Accreditation and Sale
  • Policy and Procedure Review and Development
  • Staff, Physician and Board Member training
  • Accreditation Readiness Assessment and Mock Survey
  • On-site Leadership during Accreditation Site Visit

SHP Leadership Engaged

Cindy Segar-Miller, RN, FACHE | Principal
Cindy Segar-Miller, RN, FACHE, on-site Principal and Executive-level Project Consultant providing in-person and remote day-to-day leadership at the surgery center while collaborating with facility owners, board members, clinical and non-clinical staff, vendors, and the accrediting body.

“It was an urgent situation. The surgery center needed accreditation to proceed with the sale. We conducted a full cycle assessment of where the practice stood related to the required standards for accreditation. Using the accreditation manual, we went standard by standard, line by line, to assess the current conditions and then initiate the actions necessary to bring the center into compliance.”
– Cindy Segar-Miller

The Client

Physician-owned Ambulatory Surgery Center

The Situation

Spectrum Health Partners (SHP) was engaged in November 2021 to ensure that the surgery center was prepared to undergo and achieve accreditation by the accrediting body to meet the Medicare Conditions of Participation for Ambulatory Surgical Centers. The sale of the facility was conditional based on the center successfully obtaining deemed status of accreditation.

Length of Engagement

November 2021 to June 2022

Stakeholder Groups, Representing All Functional Areas:

  • Executive Leadership
  • Board of Directors
  • Clinical staff
  • Non-clinical staff
  • Vendors
  • Accrediting body

The Work – Select Accomplishments

  • Full cycle assessment
  • Environmental and life safety assessments
  • Comprehensive document reviews and revisions
  • Revised and created policies and procedures to meet each of 15 functional chapters specific accreditation standards with multiple sub-categories for each
  • Submitted application for accreditation
  • Prepared educational materials
  • Conducted staff and board member trainings
  • Conducted mock survey
  • Provided leadership during the on-site visit

15 Accreditation Functional Chapters Standards Met

  1. Governing Body and Management
  2. Administration
  3. Surgical Services
  4. Quality Assessment Performance Improvement
  5. Physical Environment
  6. Medical Staff
  7. Nursing Services
  8. Medical Records
  9. Pharmaceutical Services
  10. Laboratory and Radiology Services
  11. Patient Rights
  12. Infection Control
  13. Patient Admission, Assessment and Discharge
  14. Life Safety
  15. Emergency Management

Client Testimonials for Cindy Segar-Miller’s Work on This Engagement

“It is my pleasure to recommend Cindy Segar-Miller as a consultant. I had the most positive experience with Cindy during the past seven months when she helped us with the monumental task of attaining accreditation for our ambulatory surgery center (ASC). I experienced her impressive knowledge, strong work ethic, problem-solving skills, and her attention to the important minute details of policy and procedures required to run an ASC.

Cindy provided positive, constructive guidance at every step. Her input was most constructive towards the needed changes and preparation required for our accreditation with ACHC. We have continued with her guidance as we move on to our day-to-day work at our center.”
Board of Trustees Member, Ambulatory Surgery Center

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Cindy Segar-Miller, FACHE

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