Flu vaccination standards set for ASCs and OBSs

In order to receive accreditation from The Joint Commission (TJC), ambulatory surgery centers (ASCs) and office-based surgery (OBS) practices must establish an annual influenza vaccination program for licensed independent practitioners and staff. This TJC accreditation requirement took effect July 1. The Joint Commission standard on influenza vaccination previously applied only to hospitals and long-term care facilities, but has been expanded to include all accredited organizations, including those accredited under the ASC and OBS programs.

In addition to the 2012 requirement to establish a vaccination program, the standard will require surgery centers and practices to:

  • Phase in other actions designed to improve vaccination rates, specifically the requirements to set incremental goals for meeting a 90 percent coverage rate by 2020
  • Develop a written description of the methodology used to determine influenza vaccination rates
  • Improve vaccination rates according to established goals at least annually starting in 2013

Although the standard will require ASCs and OBS practices to provide influenza vaccination at sites and times accessible to licensed independent practitioners and staff, it is important to note that vaccination itself is not mandatory for accreditation.


The rationale for the expansion of the standard is straightforward: Vaccination is the single most effective method for preventing influenza deaths and illnesses across all health care settings. Despite the evidence supporting this rationale, the U.S. Department of Health and Human Services (HHS) reports that vaccination rates for health care professionals remain below 60 percent. Furthermore, the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Society for Healthcare Epidemiology of America (SHEA) have all also recommended influenza vaccination for all health care professionals.

In 2010, HHS issued an action plan in which it called on The Joint Commission to help meet national objectives for increasing influenza vaccination rates. That plan noted that expanding requirements to outpatient settings is a fundamental component of improving patient outcomes and protecting health care professionals.

The Joint Commission last year sought input from accredited organizations, including ASCs and OBS practices, on the expanded standard. This field review drew more than 2,000 responses, although a breakdown of responses from specific accredited organizations is not available at this time. Most respondents indicated that their organizations have offered influenza vaccination to staff and licensed independent practitioners for five years or more.

Before recommending approval, The Joint Commission Professional and Technical Advisory Committees also considered concerns about resource allocations necessary to comply with the expanded requirements.

For more information about the influenza vaccination standard, visit TJC. Information is available about the elements of performance for the vaccination standard that took effect July 1, as well as specifics about three of the elements of performance that will be phased in by July 1, 2013, for ASCs and OBS practices, reference information, and outstanding issues related to performance measures for vaccination rates.

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