Accreditation & Quality

Fully accredited, fully credentialed.

Downey Outpatient Surgery Center is accredited by The Joint Commission, Medicare-certified, and licensed by California — a fully credentialed ambulatory surgery center. Every physician on our medical staff is credentialed through a formal primary-source verification process, and our quality program operates continuously under those standards.

Current status — The Joint Commission facility accredited; Medicare certified; California state licensed. Copies of current certificates are available on request for credentialing and payer files.

The Joint Commission accreditation

The Joint Commission is a leading independent, not-for-profit organization that accredits and certifies healthcare organizations and programs in the United States, including ambulatory surgery centers. Joint Commission accreditation is a voluntary, peer-reviewed evaluation of a facility’s governance, clinical practices, patient safety, and quality program.

DOSC successfully completed the Joint Commission accreditation process, which includes:

Application and self-assessment against the Joint Commission’s Ambulatory Care standards
On-site survey by Joint Commission surveyors (physicians, nurses, and administrators)
Corrective-action response where indicated
Accreditation decision by The Joint Commission

Our facility operates continuously against the Joint Commission standards between surveys — accreditation is treated as an ongoing commitment, not a one-time event. DOSC displays the Joint Commission Gold Seal of Approval®, and a copy of the current accreditation certificate is available on request.

Medicare certification

DOSC is Medicare-certified by the Centers for Medicare & Medicaid Services (CMS) as an Ambulatory Surgical Center (ASC), and we bill Medicare directly for covered facility services. Medicare certification requires compliance with the CMS Conditions for Coverage for ASCs, including governance, quality assessment / performance improvement (QAPI), infection control, pharmaceutical services, and patient rights.

Our billing team works with Medicare, Medicare Advantage plans, and all major commercial carriers. Medical-lien cases are handled through a separate intake channel; the treating physician’s office can coordinate directly with our billing team.

California state licensure

DOSC is licensed and operates under the oversight of the California Department of Public Health (CDPH), consistent with California regulations governing ambulatory surgical facilities and the services we provide.

Medical staff & credentialing

Every physician operating at DOSC is credentialed through our Medical Staff Office, with verification of:

Current California medical license (primary-source verified)
DEA registration (if applicable)
Board certification
Malpractice insurance with active coverage
NPDB self-query within 180 days
Peer references
Health clearance and immunization documentation

Re-credentialing follows a standard two-year cycle. Full details on the For Physicians page.

Anesthesia standards

Anesthesia providers (anesthesiologists and CRNAs) are credentialed through the same Medical Staff process as surgeons. Anesthesia practice at DOSC adheres to ASA standards for:

Pre-anesthetic evaluation
Intra-operative monitoring (ECG, SpO2, EtCO2, NIBP, temperature as indicated)
Post-anesthesia recovery (PACU Phase I / Phase II) with defined discharge criteria
Malignant hyperthermia protocol with dantrolene on-site
Difficult-airway cart availability

Quality & safety program

DOSC’s quality program reviews clinical and operational metrics on an ongoing basis, including:

Pre-procedure time-out compliance (Universal Protocol)
Surgical-site infection surveillance
Unplanned transfers to higher level of care
Medication-error reporting
Patient satisfaction and complaint review
Peer review on adverse events and near-miss reports

Findings from quality review feed back into clinical policies, credentialing decisions, and staff education. Quality metrics are not published publicly — they’re available to physicians and regulatory bodies on request.

Patient rights

Every patient treated at DOSC has the right to:

Information about their care, risks, and alternatives (informed consent)
Respectful treatment regardless of race, ethnicity, gender, sexual orientation, religion, or source of payment
Privacy of their health information (HIPAA)
Participation in care decisions
File a grievance without retaliation

Full patient-rights notice is provided at intake.

Accreditation & quality contact

Questions about accreditation status, quality metrics, or patient-rights matters:

Quality & Accreditation

[email protected]

Medical Director

This page reflects our current accreditation and licensure. Copies of the Joint Commission accreditation certificate, Medicare CCN letter, and California state license are available on request for credentialing, payer enrollment, or attorney files.

Questions about quality or accreditation?

We’re happy to share certificates, policies, or QAPI program details with your credentialing team.

Email Quality Call (562) 555-0100

What Joint Commission accreditation means for patient safety at an ASC

Accreditation is one of the clearest signals a patient can use when evaluating an ambulatory surgery center. It reflects an independent review of how a facility organizes care, trains staff, and prevents the kinds of errors that matter most in a surgical setting.

Joint Commission accreditation is a voluntary process. A surgery center invites an external body to examine its operations against published standards, then submits to periodic on-site surveys. Surveyors observe real workflows: how instruments are sterilized, how medications are labeled and stored, how staff confirm patient identity, and how the team responds when something does not go as planned. Accreditation is not a single test passed once; it is a standing commitment that a center renews on a recurring cycle.

For an ambulatory surgery center, accreditation and patient safety are closely linked because the standards concentrate on the moments where risk is highest. Several areas receive particular attention:

Surgical site verification. Structured time-out procedures confirm the correct patient, procedure, and site before an incision is made.
Infection prevention. Documented sterilization, hand hygiene, and environmental cleaning protocols are reviewed against current standards.
Medication management. Labeling, storage, and administration steps are checked to reduce the chance of a dosing or identity error.
Emergency readiness. Staff training, equipment checks, and transfer agreements are examined so the team is prepared for rare but serious events.

What accreditation does not do is promise a specific result for any individual. Surgical outcomes depend on a patient's health, the nature of the procedure, and factors that no facility can fully control. Accreditation speaks to the reliability of the systems around the procedure, not to a personal outcome. It tells a patient that the center has been measured against a recognized benchmark and has agreed to keep meeting it.

Patients preparing for a procedure can use accreditation status as one useful question among several. It is reasonable to ask when a center was last surveyed, which body accredits it, and how staff are trained on the safety protocols above. A center that welcomes those questions is demonstrating the same transparency the accreditation process is built to encourage.

Accreditation should be read alongside other information: a surgeon's experience with the specific procedure, the anesthesia plan, and the recovery support a patient will have at home. Taken together, these details give a fuller picture than any single credential can provide on its own.

This page is informational and is not medical advice. Treatment options should always be made in consultation with a qualified physician.