REGULATORY ISSUES

The activities that occur in the OR are both complex and critical in the delivery of health care. It is not surprising, then, that a large number of agencies and regulations oversee how an OR functions. The OR director must be familiar with all these various agencies and regulations to ensure compliance within the OR. A partial list of these entities is found in Table 86-21 .

Much of the OR director's focus is on meeting the regulatory requirements for hospital accreditation. Other areas of focus include patient and employee safety (infective agents, fire safety, laser safety, electrical safety), as well as proper use and tracking of drugs and medical devices.

State and local regulations, as well as hospital policies, will also have specific requirements for the OR. Especially important are privileging and monitoring the quality of outcomes for physicians in the OR. Internal data collection and quality measures should be designed to demonstrate the performance of both individual surgeons and the OR in general.