Accreditation & Quality
Our commitment to the highest standards of patient safety, quality of care, and regulatory compliance.
Beth Israel Lahey Health Surgery Center Plymouth is committed to the highest standards of patient safety, quality of care, and regulatory compliance — verified by independent accreditation bodies and state and federal regulators.
Accreditation & Licensure
AAAHC Accreditation In Progress
Currently in the process of obtaining accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC) — the gold standard for outpatient surgery center quality, safety, and governance.
Massachusetts State Licensure
Licensed as an ambulatory surgery center by the Massachusetts Department of Public Health (DPH), meeting all state requirements for facility operations, staffing, and patient safety.
CMS Certification In Progress
Currently in the process of obtaining CMS Certification and meeting all federal Conditions for Coverage applicable to ambulatory surgical centers.
OSHA Compliance
Full compliance with OSHA standards for healthcare facility safety, bloodborne pathogen exposure control, and staff protection programs.
Quality & Patient Safety (QAPI)
Our Quality Assurance and Performance Improvement (QAPI) program meets CMS Conditions for Coverage and is reviewed at every AAAHC survey. Our program covers:
- ✓ Regular peer review of surgical outcomes, complications, and adverse events
- ✓ Monthly quality committee meetings with physician and clinical leadership participation
- ✓ Patient satisfaction measurement and improvement planning
- ✓ Benchmarking against national ASC quality data
- ✓ Tracking of unplanned returns to the OR, hospital transfers, and post-operative complications
- ✓ Medication management and pharmacy safety oversight
- ✓ Staff credentialing, privileging, and ongoing professional practice evaluation (OPPE)
Infection Prevention
Surveillance & Monitoring
- Monthly surgical site infection (SSI) rate tracking
- Hand hygiene compliance audits
- Environmental cleaning verification
- Sterilization and biological indicator testing
Standards Followed
- CDC Guidelines for Prevention of Surgical Site Infection
- AORN Standards for Perioperative Practice
- APIC infection prevention framework
- Massachusetts DPH infection control regulations
Physician Credentialing
All physicians performing procedures at our facility undergo thorough credentialing and privileging, including:
- Verification of board certification and current medical licensure
- Review of malpractice history and adverse actions
- Procedure-specific privilege requests and governing board approval
- Ongoing Professional Practice Evaluation (OPPE) for all medical staff
- Focused Professional Practice Evaluation (FPPE) for new or expanded privileges