Mastectomy Facility Accreditation Guide

Our goal is to make the accreditation process as effective and uncomplicated as possible. The following information will help you understand what you can expect from the process.

Preparing for your Survey

Before applying, you should make sure your facility is compliant with the eligibility criteria and the Standards. We offer a variety of accreditation tools on our website. The Custom Standards tool is one important tool that will assist you in determining which Standards apply to the product categories you are providing. Accredited facilities also have access to our online Compliance Kit Resource Pack. Additional preparation resources can be found in the Resources & Links section .

Survey Structure

Initial Interview

Your surveyor(s) will conduct an initial meeting with your facility’s survey contact or designated representative. At this time, the lead surveyor will:

• Briefly introduce him/herself, along with other members of the survey team (if applicable)
• Discuss the survey objectives and the day’s schedule
• Answer any questions you may have regarding the survey
• Ask for the general layout of your facility and a description of any other details about your facility and your staff that should be noted

Information Gathering

To verify that you have met the requirements of ABC’s Mastectomy Accreditation Standards; your surveyor will review many areas, including:

• Personnel files
• Patient records
• Accounting and bookkeeping records
• Contracts with vendors, staff members
• Agreements with physician’s offices
• Fire safety and emergency management plans and documentation
• Patient satisfaction surveys and results
• Business policies and procedures
• Product delivery information

By applying for accreditation, you authorize ABC and our surveyor’s access to all records (including patient, personnel, financial management, risk management, operational review, quality assurance and quality improvement) and physical areas necessary to determine your facility’s compliance with the ABC Standards. Your surveyor will also conduct staff and patient interviews and may look at other areas as they relate to the Standards. All Protected Health Information (PHI) is treated in accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations. Per CMS, surveyors are required to call a sampling of your facility’s Medicare patients and ask the patient or caregiver a few questions about the device, education, and follow-up they received. We recommend that a staff member be present while your surveyor makes these calls.

Closing Interview

During the closing interview, your surveyor(s) will discuss general survey findings. This interview provides you with a final opportunity to clarify any information or present documentation that may not have been available to your surveyor during the course of the survey. All significant recommendations and deficiencies will be discussed with you.

Your surveyor cannot provide judgment as to whether your facility will be granted accreditation and is not permitted to discuss whether your facility has passed or failed. Your surveyor’s role is to review the information presented and to clarify, observe and verify that the data supports your compliance with the applicable standards. Your surveyor may also provide suggestions that could help improve your business practice.

In the event that the ABC Patient Care Facility Accreditation Standards are revised, we will establish a time frame for you to achieve compliance. Remember, it is your responsibility to ensure that you are in compliance with the ABC Standards at all times.

After the Survey - Results

Scoring Process

Your surveyor will submit their initial findings to ABC. They cannot give you the final survey score during the onsite survey, as all results must be validated and finalized by staff. Finalized results will be emailed within 2-4 weeks and mailed within 6-8 weeks. Results for reaccreditation surveys are not processed if there are any outstanding invoices, such as annual fees. Any questions regarding accreditation status should be directed to the ABC Facility Accreditation staff at accreditation@abcop.org.

Accreditation Decision

Once your survey results have been validated and processed, you will receive an email decision with access to your facility’s decision letter, survey report, and certificate (if applicable). Your facility’s decision letter and certificate (if applicable) will also be mailed to your facility. The report will indicate a score of Compliant, Partially Compliant or Non-Compliant for each standard for which your facility was surveyed. Standards marked Partially Compliant or Non-Compliant will include comments to assist you in taking corrective action to meet the standard. Your decision letter will inform you of your accreditation status and any additional action necessary, including if you need to submit a Corrective Action Plan (CAP). Accreditation certificates are the property of ABC and must be returned upon request.