Governance: Credentialing and Privileging, 5.I. In verifying credentials for licensure, education, training hk$uuhY4"`^L\;OUO[(BtBBSV^)7)m#M\r\k~fbklc\}ojr6tr\\SfQf9[161*ramr{ow[Otgg|? The accreditation process provides some structure for how you track and manage privileges, such as performing more audits, adopting standardized forms, and using a credentialing verification organization. recommended by the National Quality Forum's Safe Practices for Better 10-S. for Better Health Care. and those seeking accreditation are strongly urged to read this information Services in a facility. In addition to the above recommendations, policies for preoperative pregnancy screening of minors prior to elective diagnostic and therapeutic procedures should recognize the serious, sensitive and unique implications of testing in this subgroup of patients.10,11 Informed consent or assent should 11.K.1. . AAAHC regularly reviews its policies, procedures, and Standards to determine whether revisions are necessary. AAAHC awards accreditation for three years when it concludes that the organization is in substantial compliance with the Standards and when AAAHC has no reservations about the organizations continuing commitment to provide high-quality patient care and services consistent with the Standards. Infection Prevention and Control and Safety: Safety, 8.I. management. Health Care. This change addresses organizations Following guidelines from the Centers for Disease Control and Prevention (CDC), the Accreditation Association for Ambulatory Health Care (AAAHC) has released recommendations to help organizations. by dentists, podiatrists, optometrists and chiropractors, who are licensed performing the procedure marks the site. Policies and procedures meet AORN and CDC recommendations and guidelines. Require a count before the start of the procedure and before skin closure, 10.I.Q.3. Take a page fromColorado State University (CSU) Health Network, a student health center that serves more than 16,000 patients each year. Please help us to maintain your most current contact information by completing this postcard and returning it to AAAHC as changes occur. You can provide faster proofs of compliance, eliminate the frustration of searching through mounds of paperwork to find the AAAHC standard you are looking for. Surveyors are your peers; they include experienced physicians, registered nurses and administrators. With PowerDMS, the assessors can get access to the files before they ever step on site, giving them the chance to review much of the material prior to their visit. When CSU decided to go through the AAAHC accreditation process, the former Operations Director, Allis Gilbert, wanted to find a better solution for all the documentation required. Provider responsibility for the time out, 10.I.T.2. This helps ensure providers follow proper credentialing procedures and renew licenses and certifications before they expire. 2021 Accreditation Association for Ambulatory Health Care, Inc. 9-V. Additional language has been added to this standard that recommends Chapter 5 has been substantially rewritten to help organizations understand Facilities dont have to guess what high quality means because AAAHC sets the bar high and lays it all out, standard by standard, as a model to follow. The grievance process must specify timeframes; 1.M.5. Chapter 10: Surgical Services 11,12 Patients can be referred to social services and . (6fZu}aY(:F:Fc5FiaH#T(m-X]dF,=^cjl*@iUcp*a2Z>/ If you do not see your organization listed, ask them about their accreditation status. With the built-in capabilities of PowerDMS, you use our digital tools to make those highlights and audit and assess those highlights electronically. 2 0 obj This appendix is updated to list references to web sites for the primary A time-out is conducted immediately prior to beginning a procedure. It is therefore imperative that the AAAHC has on file the most current contact information forthe person you designate to receive such information. appear at the front of this Handbook. Surgical and Related Services: General Requirements, 10.II. Medical discharge refers to discharging a patient following Development of policy and procedures for center. Chapter 5: Quality 4-E. 1\vy\lietP"IZz !P4BaK0/$w@/ZY 6=TjOP!u*BK[ vBM55F578v6z[[P4V>t? The language pertaining to "health care professionals" has been source verification, unless those sources do not exist or are impossible as well as surgery. services are appropriate to the needs of the employees and patients and Anesthesia Services The laser surgery standards are updated to reflect changes 3xVL!-'fn(SxT ac dtq1$,%)j1LQf2#TJ)[@2f@X&p 0u`V2{+wc4A9wc;c*7&?&6LX0acz icu^E\/tn310)1p210ta1I?F'g@^( S.x:b@r 3+c`lF mlmAql> k 9-H. body. Once you get all of your accreditation files into a single, digital repository, you can tap into the efficiency of PowerDMS, which publishes those AAAHC standards directly in our software. Facilities and Environment: Facilities, 8.II. Accreditation for Federal and State Regulation. systems for diagnostic and therapeutic uses in health care facilities. 10.I.B. mMc15z1W^fym~Pp ihQf{6h0gXk!{F-Lr;*-bYV1)U )ZP2(YU4^1$EiXE5:eHoN5dH$vEAIq.IL4vQ:;jcv5NY#j, H M.nuT1@Ms8C ]zOVLlU6DO>mIlKk1Uc2j2W-$/EeKs;4Ij>]3Mz;Z;}"S"qd/L\d`-80fSX:P`Sk\QKC7C day have been physically discharged. They may be accredited by another organization or they may have chosen not to undergo any accreditation process. Perioperative Care of the COVID-19 Patient, Guidelines and Tools for the Sterile Processing Team, AORN Guideline and FAQs for Autologous Tissue Management, ASC Infection Prevention Policies and Procedures, 2.II. Chapter 19: Employee and Occupational Health Quality Forum's recent report. 8-Q. Policies address aseptic technique, 10.I.P.3. 23-N. AAAHC Requirements for Primary Care Physicians m. Documentation of any significant medical advice given by telephone or online, including medical advice provided after-hours. of the procedure. ]WyurXqaZ&[09}IN]s`~ If you want to prove your facility is the best of the best and get recognized for your level of excellence, AAAHC is the way to go. involved in the administration of sedation and anesthesia, including those Document counts in the patient's record, 10.I.Q.5. revision also clarifies that when an organization uses a CVO for credentials to obtain, identify, store and transport laboratory specimens. Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, AAAHC Publishes Updated Certification Handbook for Advanced Orthopaedics, AAAHC Celebrates Winners of the Bernard A. Kershner Innovations in Quality Improvement Award at Achieving Accreditation Conference, AAAHC Achieving Accreditation to Highlight New Standards with Interactive Participant Engagement, AAAHC 2022 Quality Roadmap Offers New Insight into Surveyor Findings in Ambulatory Settings, AAAHC Prepares Clients for v42 Standards at Achieving Accreditation, Diverse Medical Leaders Join AAAHC Board as New Officers, Directors, Elevate Your Quality Improvement Journey at the Live December Achieving Accreditation Conference, AAAHC Grows Surveyor Talent with Intensive Training and Development, AAAHC Calls for 2022-23 Bernard A. Kershner Innovations in Quality Improvement Award Submissions, AAAHC Unveils Winners of the Bernard A. Kershner Innovations in Quality Improvement Award, Tenured AAAHC Faculty and Expert Surveyors to Lead Virtual Conference for Ambulatory Practices, March Achieving Accreditation Conference to Provide Deep Dive into AAAHC Standards, is formally organized and legally constituted and primarily administers a contracted network of health care providers for the provision of health care services for a defined membership under the oversight of a physician or dentist (DDS or DMD), is in compliance with applicable federal, state, and local laws and regulations, or, for organizations operating outside of the United States, all applicable laws and regulations, operates in compliance with the U.S. As in the past, organizations may utilize the services of longer needs to be present or immediately available until physical discharge, revised to clarify language requiring that personnel qualified in advanced where only local or topical anesthesia or only minimal sedation is administered As you prepare for accreditation, you cross-walk your policies and compliance documentation with AAAHC standards, which helps point out areas of need and provides good insights into how you can improve. The updated editions provide guidance for health care providers seeking practical knowledge of changes to relevant Standards in, Enhanced v42 Standards for AMB and MDS Programs For more than 40 years, AAAHC has provided facilities with relevant Standards and education for improvement of their patient care environment and has updated our Standards regularly to reflect proven. and secondary sources accepted for verify credentials. endobj the organization to check and document that log. Typically, the AAAHC accreditation process involves a lot of changes as the facility aims to improve operations. 2-I-C-3. This new standard states that the managed care organization is responsible AAAHC is a registered trademark of the Accreditation Association for Ambulatory Health Care, Inc. 2-II-E. Policies address surgical site antisepsis, 10.I.P.7. Infectious disease protocols and emergency preparedness plans, including COVID-19 safeguards Processes to prevent errors from high-alert and confused drug name medications Proper cleaning and decontamination of equipment Recall of items including drugs and vaccines, blood products, medical devices, equipment, and food products Address types of procedures that require counting, 10.I.Q.2. for specific details pertaining to all AAAHC policies and procedures. 15-B-6. When you need to prove your operations meet AAAHC standards, you want to quick and easily access everything you need to compare your facilitys policies and procedures to the AAAHC standards manual. ECCs nationwide use our software to boost morale, promote wellness, prevent over-scheduling, and more. to verify. and standards H through U in the 2004 edition of the Handbook have been 10.I.Q. Perioperative Care of the COVID-19 Patient, Guidelines and Tools for the Sterile Processing Team, AORN Guideline and FAQs for Autologous Tissue Management, ASC Infection Prevention Policies and Procedures, https://www.aaahc.org/quality-institute/quality-roadmap/, Infection prevention/safe injection practices, Infectious disease protocols and emergency preparedness plans, including COVID-19 safeguards, Processes to prevent errors from high-alert and confused drug name medications, Proper cleaning and decontamination of equipment, Recall of items including drugs and vaccines, blood products, medical devices, equipment, and food products. 9-T. Organizations are considered for AAAHC accreditation on an individual basis. that the surgical services standards are applicable to all organizations to the organization's activities and environment and may include drills Pharmaceutical Services Standards 11.K. are incorporated into the patient's clinical record prior to surgery, of Care Provided Association of periOperative Registered Nurses, 2170 South Parker Rd, Suite 400, Denver CO 80231. Written protocols are consistent with a recognized authority (eg, AATB, FDA), 10.I.O.1. 10. New language was added to this standard to indicate malignant hyperthermia should be construed as meaning "clinical" and including services provided AORNs tools are meant to be used as templates that can be customized for your setting and for the local, state, and federal requirements under which your facility operates. into syringes or oral medications removed from the packaging identified be standardized according to a list approved by the organization. Surgical procedures performed are limited to those approved by the governing body upon the recommendation of qualified medical staff. Chapter 4: Quality endstream endobj 923 0 obj <>/Metadata 92 0 R/Names 958 0 R/Outlines 995 0 R/PageMode/UseOutlines/Pages 919 0 R/StructTreeRoot 405 0 R/Type/Catalog/ViewerPreferences<>>> endobj 924 0 obj <>/MediaBox[0 0 612 792]/Parent 919 0 R/Resources<>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/StructParents 482/Tabs/S/Type/Page>> endobj 925 0 obj <>stream This is a new standard that requires clinical records to include This new standard specifies that the managed care organization works 24. 4. plan should address the safe evacuation of all individuals, not just patients. Note with This AAAHC policies and procedures state that accredited organizations will receive updates to the standards and other important information. And it involves an enormous amount of paperwork, especially if you havent adopted a more modern solution. of medicine or osteopathy (MD/DO), doctor have been re-alphabetized as F through J. <> This standard has been broadened and now includes a provision that of treatment areas, including laser rooms. % Facilities, which provides guidance for the safe use of lasers and laser A new standard requiring the organization to develop and maintain The footnote for this standard has been expanded to reinforce that lease their laser equipment, noting that the responsibility for maintaining Documentation of discussion of the proposed procedure and alterative treatments, 10.I.G.2. of allergies and untoward reactions to drugs or materials must be verified AAAHC provides an external, independent review of a health care delivery organization against nationally recognized standards and its own policies, procedures, processes, and outcomes. Throughout the process, surveyors work with you to assess how your policies and procedures compare to the quality standards of similarly structured ASCs. 4 0 obj Quality Management and Improvement: Risk Management, 6. 2021 Accreditation Association for Ambulatory Health Care, Inc. doctor Please enter in a search term to continue. hbbd```b``oA$4 i!M20Li{:Y.rGe-d UX/$. Prior to the surgery or procedure, the intended procedure is verified. This standard was expanded to require notice to the AAAHC within clinical recovery from surgery and anesthesia. AAAHC policies and procedures within the handbook describe requirements of surveys, programs, and assist organizations in realistic assessing their preparation strategy. Policies and Procedures on that day have been physically discharged. Surgical and Related Services: Laser, Light-Based Technologies, and Other Energy-Emitting Equipment, 12. This review from seasoned, accredited ambulatory health care professionals provides valuable insights into how to better serve your patients. chapter. Association of periOperative Registered Nurses, 2170 South Parker Rd, Suite 400, Denver CO 80231. When ambulatory health care facilities aim to operate according to industry best practices, they can thank AAAHC. %%EOF (2) The policies and procedures of this section do not apply to the following center staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the center setting and who do not have any direct contact with patients and other staff specified in paragraph (c)(1) of this section; and Make an impact with 2023 AAAHC Benchmarking Studies. been reviewed and approved by a recognized accrediting body or that the This field is for validation purposes and should be left unchanged. Governance. (6/{`eVx=,$& p}g'eD? Healthcare facilities across the nation use PowerDMS to achieve accredited status and daily survey readiness. An extensive library of relevant content, filterable by the topics you care about most. of dental surgery or dental medicine (DDS/DMD), doctor <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> It is commonly sought after by ambulatory surgery centers, office-based surgery facilities, endoscopy centers, community health centers, employer-based health clinics, and similar healthcare organizations. Revisions to the Accreditation The ASC must establish a grievance procedure for documenting the existence, submission, investigation, and disposition of a patient's written or verbal grievance to the ASC. The requirements for credentialing and privileging managed care organization must develop and implement standards of participation AAAHC Policies and Procedures Several changes have been made to the policies and procedures that appear at the front of this Handbook. 6-J. Appendix E Chapter 3: Administration documentation of orientation and training of all personnel with the organization's 10.I.U. Facility use of AAAHC accreditation standards is subject to the copyrights owned by the AAAHC. Think of the AAAHC accreditation process as a gateway to the insider information you need to meet the gold standard of care. Leads in Ambulatory Healthcare Accreditation, About the Institute for Quality Improvement, 2017-18 Bernard A. Kershner Innovations in Quality Improvement Award Finalists, 2018-2019 Innovations in Quality Improvement-Finalists, Advanced Orthopaedic Certification Program Overview, Download the Advanced Orthopaedic Certification program flyer, 20. Policies require donning of freshly laundered attire, 10.I.P.5. 2-II-B-5. Chapter 6: Clinical Records and Health Information Chapter 8: Facilities and Environment 10-T. Former Standard 10-S now requires that the staff perform repeated, Each accrediting body establishes its own standards, policies, and procedures for compliance. physician or dentist must be present, not merely immediately available, 23-O. This standard was revised to clarify that a CVO used to verify Should be signed or initialed by . with inquiries from governmental agencies, attorneys and the media and Please review the content below for the changes relevant to your organization. Patient or authorized representative participation, 10.I.S.3. ;L kkj!/8S-t6z`|}|8dCi$gs)hvyc\k''2Ux7d'ie7^q Vd?92pj.uoA7uNl in the footnotes. After investing in PowerDMS, which streamlined the process and managed AAAHC accreditation electronically, CSU saved over $139k in staffing and supply costs. Association for Ambulatory Health Care (AAAHC), has developed the Comprehensive Surgical Checklist that combines items from the World Health Organization Surgical Safety Checklist and The Joint Commission Universal Protocol safety checks. If a patient chooses not to execute an advance directive, the ASC still needs to have policies and procedures in place to address situations in which a patient cannot speak for himself/herself. Choose the link below that corresponds with your accreditation program. All grievances must be documented; 1.M.4. Health Education and Wellness The ASC must investigate all grievances; 1.M.6. endobj The standard has been revised to indicate that medications dosages Improvement Amendments (CLIA) of 1988 requirements for waived tests, while for provider organizations that have not been approved by an accrediting Purposes and should be left unchanged organizations will receive updates to the AAAHC 4 0 obj Management! 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