TFC Surgery Center Management

Policy & Procedures

Aesthetic Services

Treatment Protocol for Botulinum Toxin Type A Treatment Protocol for Calcium Hydroxylapatite Dermal Filler Treatment Protocol for Deoxycholic Acid (Kybella) Treatment Protocol for Hyaluronic Acid Dermal Filler Treatment Protocol for Laser Light Therapy Treatment Protocol for Poly-L Lactic Acid (Sculptra)

Anesthesia Services

Anesthesiology Guidelines based on ASA Guidelines Anesthesia Apparatus Check Recommendations Anesthesia Care Plan Anesthesia Informed Consent Anesthesia Quality Improvement Anesthesia Quality Assurance Indicator Sheets Areas of Sedation ASA Classification System Certified Registered Nurse Anesthetists (CRNA) Duties and Responsibilities Deeper than Expected Sedation Documentation in the Medical Record General Anesthesia Infection Control Intra-operative Anesthesia Monitoring and Documentation Intravenous Sedation/Procedural Sedation Levels of Sedation Malignant Hyperthermia PACU Pre-Anesthesia Evaluation Review and Approval

Clinical Record & Health Information

Audits and Evaluations Chart Review Closing Patient Files Confidentiality Corrective Action Device and Media Controls Disposal of PHI Email, Instant Messaging, and Internet Use Emergency/Disaster Contingency Plan Faxing Private Health Information Medical Records Medical Records Standardization Notification of Breach of Unsecured PHI Passwords Patient Correspondence Patient Medical Records Release Physical Security Protected Health Information (PHI) Records Retention Security Incident Management Workstation Use Workstation Security Review and Approval

Covid-19

Cleaning and Disinfection Infection Prevention and Control Patient Screening Staff, Contractor and Consultant Screening, Illness and Testing Review and Approval

Environment of Care

Emergency Preparedness Plan Equipment Management Plan Hazardous Material and Waste Management Plan Impaired Physician Plan Incapacitated Physician Plan Incident Reporting Processing Physicians Orders Safety Management Plan Security Management Plan Utilities Management Plan Violent and Aggressive Patients & Visitors Visiting Physicians and Allied Health Professionals Workplace Violence Review and Approval

Hazard Communication

Plan Overview Fire Safety Guidelines for Cleaning a Chemical Spill Hazard Classes and Storage Knowledge of SDS National Fire Protection Association Rating Codes Right to Know Safety Practices Staff and Employee Communication Staff Training Workplace Corrosives Review and Approval

Infection Control & Prevention

Autoclave Cleaning Basic Aseptic Technique Checking of Needles/Glove Boxes Cleaning of Anesthesia Equipment Cleaning of Brushes Contagious Disease and Tuberculosis Employee Health Food and Drink in a Clinical Setting Guidelines Resources Guidelines for Gowning and Gloving Handling and Storage of Sterile Supplies Infection Control Plan Laundry Services per CDC Guidelines Loaner Instruments and External Vendor Processing Maintenance and Repair of Reusable Medical Equipment & Medical Devices Operating Room Sanitation Refrigerator/Freezer Cleaning per CDC Guidelines Reporting to the Hawaii State Department of Health Selection and Use of Packaging Materials Selection of Gowns and Drapes Shelf-Life Guidelines Spore Testing per CDC Guidelines Sterile Processing per CDC Guidelines Sterile Supply Check Sterilization and Disinfection Guidelines per CDC Guidelines Storage of Sterile Packaged Materials per CDC Guidelines Surgical Hand Scrub Review and Approval

Medical Laboratory Services

CLIA Waiver Glucose Test Quality Control Glucose Tests Lab Test Results Outside Laboratory Testing Proficiency Testing Specimen Handling Test Kits, Laboratory Devices and Supporting Supplies Tissue Exemption Urine Pregnancy Test Quality Control Urine Pregnancy Tests Use of the Centrifuge Venipuncture Review and Approval

Rights of Patients

Abusive Patient/Visitor Advance Directives After Hour Phone Message/Emergency Care Grievances Interpreter Services Patient Confidentiality Patient Follow-Up of Missed Appointment Patient Rights and Responsibilities Patient Satisfaction Surveys Patient Termination of Services Patient/Family Education Patient/Parent or Legal Guardian Complaints Resolution of Conflict in Care and Treatment Decisions Restraints and Seclusion Suspected or Actual Patient Abuse Plan Termination of Services Treatment of a Minor Understanding of Informed Consent, Patient/Parent or Legal Guardian Review and Approval

Surgical Services

Adverse Events Approved Medical Abbreviations Assessment and Management of Pain Attire in the Operating Room Authenticating Orders Blood Transfusions Code Responses DVT Risk Assessment Emergency Cart Fat Grafting Implants Documentation and Tracking Intra-Operative and Post-Operative Reports Patient Care Orders Patient Safety in the Procedure Room Patient Selection Criteria Physician Protocol for Local Anesthesia Procedures Post Op Phone Call Post Procedure Instructions Post-op Visit Pre-Operative Checklist Pre-Procedure Instructions Psychological Evaluations Scope of Practice Sponge, Sharps, and Instrument Counts Standing Order Surgical Site Markings Surgical Suite and Operating Room Time-Out Verification Visitors in the Procedure/Operating Room Review and Approval