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Our Quality

Orthopaedic & Spine Center of Southern Colorado is committed to providing quality service and extraordinary care to our patients and their families. We provide exceptional, world-class care from the moment you arrive. Our goal is to make you comfortable and well-informed during your time with us. Our staff would like for you to experience this world class care from the moment you enter the facility.

Our Medical Staff

Orthopaedic & Spine Center of Southern Colorado is proud to work with experienced and well-qualified medical staff. Prior to granting providers privileges to Orthopaedic & Spine Center of Southern Colorado, our medical staff office completes a standard credentialing process. This provider credentialing process is the same process hospitals and other large health organizations use to validate surgeons’ education, background, and qualifications.

Our physicians comply with state and federal regulations as well as practice standards set forth by our accreditation organization. Each provider at our center is licensed by the state board of medical examiners. Most of them are also board certified in their practice specialty.

Provider Trust ®

Our ASC meets prescriptive guidelines issued by the Office of Inspector General for concurrent monitoring of fraud and abuse committed by health care professionals and medical manufacturers of goods or services.

If you have any questions or concerns about our medical staff or providers, please do not hesitate to contact our business office at (719) 282-8888.

Patient Pre-Admission Standards

At Orthopaedic & Spine Center of Southern Colorado, we understand every patient is unique. Using your health history, we apply our admission criteria to evaluate suitability for same-day discharge. If you have multiple active health conditions, an anesthesia provider is consulted. Diagnostic tests may be ordered before making the decision to proceed with your procedure.

If you are identified as a patient who requires resources greater than our ASC can provide, we notify your surgeon. Our primary concern is your safety.

If you have any questions about our pre-admission process, please contact our peri-operative nurse at (719) 282-8888.

Post-Procedure Process

Orthopaedic & Spine Center of Southern Colorado strives to provide you with compassionate care.  Our professional nursing staff assesses your physical condition prior to and immediately following surgery.  They intervene as necessary to advance your recovery progress and assist with preparations for your safe discharge home.

Our discharge plans include the following elements:

  • Verifying you have a person designated as your caretaker who will attend to your care at home.
  • Assessing your physical condition for the duration of stay in our post-anesthesia recovery area.
  • Providing medication during your care to address pain, nausea, or other ailments as needed.
  • Ensuring your physical condition meets required criteria for a safe discharge home.
  • Verifying your newly prescribed medications have been obtained for pain management, with instruction on how to best manage your pain.
  • Reviewing your prescription medications and advising when to resume.
  • Instructing your designated caretaker on how to best attend to your post-procedure needs at home, including comfort measures, wound care, ambulation, food intake, showering, and other, as prescribed by your surgeon.
  • Conveying contact information for your physician or the nearest emergency department.

Our clinical staff is highly proficient in identifying and caring for patients’ needs prior to discharge.  However, if you have any questions or concerns about our discharge processes, please contact our Lead Nurse at (719) 282-8888.

Preventing Emergencies

Patient Health-Related Emergencies

Surgery and other invasive procedures come with risks.  These risks were discussed with you by your attending physician when obtaining your informed consent.  Our medical and nursing professionals are trained to respond to emergencies, such as respiratory or cardiac insufficiency or arrest.

  • Certification in Advanced Cardiac Life Support (ACLS) is required for anesthesia providers and nursing professionals in our ASC’s post-anesthesia care unit,
  • The same professionals are required to hold Pediatric Advanced Life Support certification in ASCs where pediatric patients (newborn to age 18) are served.
  • Other complications of surgery or invasive procedures can occur and will be managed by a team of professionals to ensure your personal safety.
  • All unexpected patient care events are reported to our Medical Advisory Committee for quality of care evaluation.  Our goal for quality achievement is to assess our performance, plan for improvement, and provide opportunities for shared learning across our organization to prevent these events in the future.


American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care


Natural and Man-Made Disasters

When it comes to natural or man-made disasters, Orthopaedic & Spine Center of Southern Colorado complies with the Emergency Preparedness Rule set forth by Centers for Medicare & Medicaid Services (CMS).  The Emergency Preparedness Rule mandates all health care facilities have an emergency plan in place.  The plan includes assessment of risks and preparation designed to proactively manage identified threats.  Personnel are trained in emergency response.  Mock drills allow us to assess response protocols and identify opportunities to improve.

The elements of the Emergency Preparedness Plan include:

  • Risk Assessment and Planning – CMS requires an “all-hazards” integrated approach to prepare for a wide range of potential threats, focusing on those most likely to occur at our location.
  • Policies and Procedures – ASCs must develop policies and procedures which account for all occupants (patients, physicians, and personnel) during an emergency. The plan must address how to conduct patient transfers for individuals who need more specialized care during an emergency or identify when the best course of action is to provide shelter until the emergency has stabilized or is resolved.
  • Communication Plan – The communication plan coordinates all aspects of internal and external communication during an emergency, including the management of patient care and/or request for aid with agencies offering additional assistance.
  • Training and Testing – The most effective way to test preparedness for any emergency is to practice. Staff training is essential to optimize safety and minimize loss of human life or business assets.  A minimum of two emergency preparedness drills are required annually – one community-based and another facility-based or tabletop exercise.

In accordance with the Emergency Preparedness Rule set forth by CMS and the standards of care set forth by the Orthopaedic & Spine Center of Southern Colorado’s mission, vision, and values. Orthopaedic & Spine Center of Southern Colorado is prepared to respond to a wide-range of emergencies that may occur at our ASC.  Our hope is our staff does not have to use this extensive training when providing care to you or your loved ones.  In the event an emergency does occur, our team will do everything in our power to ensure the safety of our patients.

Facility Licensing

Orthopaedic & Spine Center of Southern Colorado is licensed by the state health department.  Obtaining a license requires strict adherence to state regulations.

We are also accredited by the Accreditation Association for Ambulatory Health Care, Inc. and the Center for Medicare & Medicaid Services (CMS).  ASCs with these accreditations are regularly surveyed for compliance to regulations.

Certification by Centers for Medicare & Medicaid Services (CMS)

For an ASC to receive reimbursement for services provided to Medicare or Medicaid recipients, the ASC must be certified by CMS.  Obtaining certification requires the same strict adherence to federal regulations outlined in Code for Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 416.  To qualify for certification, the ASC is evaluated for compliance to regulations by undergoing an unannounced survey.  A plan of correction is required to address any non-compliance to regulations.

Facility Accreditation

An ASC chooses to voluntarily seek accreditation from an accreditation organization.  There are three to choose from:  AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities), TJC (The Joint Commission).  Regardless of the accreditation organization selected by an ASC, securing and maintaining accreditation status requires vigilant attention to elements of performance and best practice standards.  The goal for any ASC is to integrate state, federal, and accreditation association standards into everyday performance by members of medical staff and ASC personnel.

Our ASC has chosen AAAHC as our accreditation organization.  Surveys are typically conducted every three years.  Our ASC works tirelessly to address standards as outlined by our accreditation organization.  We sustain our performance of these ongoing activities by assigning specific tasks and oversight to key personnel within our ASC.  If deficiencies are identified during survey conditions, we submit a plan of correction and must demonstrate adoption and sustained improvement to validate we have met all accreditation requirements.  Achievement of accreditation is the gold standard for delivery of care and services.  We take pride in our sustained accreditation status since opening in 2014.

For more information on the patient care standards set forth by CMS and AAAHC, please visit the following resources:

CMS Quality, Safety & Oversight – Guidance to Laws & Regulations

AAAHC Accreditation for Ambulatory Surgery Centers

Clinical Quality Metrics

Monitoring our patient outcomes is very important to us.  Our ASC’s quality management program provides us with immediate feedback on care-related events which allows us to quickly address delivery of care issues.  Our ASC monitors fifty or more performance measures important to us and our licensing and accreditation organizations.  These measures are benchmarked internally and regularly shared with our staff and governing board.  We also use external benchmarking to compare our performance against other ASCs.   Using our own data, we can focus our attention and resources in specific areas to improve patient care and day-to-day business activities.  Our goal is to optimize your experience while under our care, therefore we hope you will complete our patient satisfaction survey questionnaire.  This provides us with yet another opportunity to improve how we deliver care.

Some of the clinical quality metrics we track are surgical site infection rate, post-surgical hospital admission rate, and patient satisfaction score.  Please contact our office if you would like more detailed information at (719) 282-8888.

What is an ASC?

We get this question a lot.  Patients often wonder, what is an ASC and why should I care?  Even after visiting an ASC like Orthopaedic & Spine Center of Southern Colorado, many are unaware they have seen their physician in an ASC and they remain unaware of the value the ASC has brought to them.

Ambulatory surgery centers, or ASC, is an outpatient surgical facility licensed by the state in which it operates.  Physicians choose to perform procedures in the outpatient surgical setting for patients who are suitable for elective procedures.  Patients receiving care at an ASC are generally in good health and are discharged on the same day as their surgery to return to their home environment.  ASCs have a long history of efficiency.    Although delays occur, most ASCs maintain an on-time surgical schedule which results in less wait time for patients.  Other benefits to using an ASC instead of hospital for elective surgery or invasive procedures include:

  • Lower costs, less out of pocket expense to you
  • Less waste in medical supply consumption
  • Emergency procedures are not inserted onto our posted schedule which could result in significant delay or cancellation of your planned procedure
  • Lower post-operative wound infections

Take charge of your health!  Know your options when it comes to where to receive your health care.

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We believe extraordinary care leads to exceptional outcomes.