1. (1)       All Level II and Level III office-based surgical procedures shall be performed in a physician office that is appropriately equipped, registered with the Board, and accredited or certified by an accrediting entity approved by the Board.
2. (2)       The Board may approve an accrediting entity that demonstrates to the satisfaction of the Board that it has all of the following:
3. (a)         Standards pertaining to patient care, recordkeeping, equipment, personnel, facilities, and other related matters that are in accordance with acceptable and prevailing standards of care as determined by the Board;
4. (b)       Processes that ensure a fair and timely review and decision on any applications for accreditation or renewals thereof;
5. (c)       Processes that ensure a fair and timely review and resolution of any complaints received concerning accredited or certified physician offices; and
6. (d)       Resources sufficient to allow the accrediting entity to fulfill its duties in a timely manner.
7. (3)       A physician may perform procedures under this rule in a physician office that is not accredited or certified, provided that the physician office has submitted an application for accreditation by a Board-approved accrediting entity, and that the physician office is appropriately equipped and maintained to ensure patient safety such that the physician office meets the accreditation standards. If the physician office is not accredited or certified within one year of the physician's performance of the first procedure under this rule, the physician must cease performing procedures until the physician office is accredited or certified.
8. (4)       Proof of accreditation shall be kept on file with the Board and on site at the physician office. If a physician office loses its accreditation or certification and is no longer accredited or certified by at least one Board-approved entity, the physician shall immediately cease performing procedures in that physician office. Any changes to a physician office’s accreditation status shall be reported to the Board within five (5) business days.
9. (5)       Each physician office shall implement a quality assurance program to periodically review the physician office’s procedures and quality of care provided to patients.
10. (a)       A physician office shall engage its quality assurance program not less than annually. The quality assurance program may be administered by the physician office’s accrediting entity.
11. (b)       A registered physician and his or her partners cannot provide peer review for each other.
12. (6)       A quality assurance program shall include, but not be limited to:
13. (a)       Review of all mortalities;
14. (b)       Review of the patient selection, appropriateness, and necessity of procedures performed;
15. (c)        Review of all emergency transfers;
16. (d)       Review of surgical and anesthetic complications;
17. (e)       Review of outcomes, including postoperative infections;
18. (f)        Analysis of patient satisfaction surveys and complaints;
19. (g)       Identification of undesirable trends, including diagnostic errors, poor outcomes, follow-up of abnormal test results, medication errors, and system problems; and
20. (h)       Tracking of all deviations from the patient selection and procedure protocols, including identification of the patient, the basis for the deviation, a description of the medical decision-making supporting the deviation, a description of the outcome, and any remedial measures taken.
21. (7)       Quality assurance program findings shall be documented and incorporated into the physician office’s educational programming, protocols, and planning, as appropriate.
22. (8)       Each physician shall attest in writing to the Board that a compliant quality assurance program has been implemented prior to performing any office-based surgery. Each physician shall be responsible for producing the plan to the Board upon demand.

Author: Alabama Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §34-24-53.

History: New Rule: Filed October 17, 2003; effective November 21, 2003. Repealed and New Rule: Published January 30, 2026; effective March 16, 2026.