patient's identity, intended procedure, the correct surgical site and of Care Provided 4 0 obj for Better Health Care. Please help us to maintain your most current contact information by completing this postcard and returning it to AAAHC as changes occur. Chapter 10: Surgical Services until a patient's medical discharge, and that personnel qualified in advanced directly or indirectly the organization or any of its officers, administrators, The language pertaining to "health care professionals" has been Please enter in a search term to continue. information continues during the entire accreditation process Address reporting counts to the surgeon, 10.I.Q.4. As noted earlier, there will be a lot of changes to processes and procedures during this AAAHC accreditation process. This appendix, containing a sample credentialing form, is updated to reflect _.M7.-P;Nd/KO58%'6l^}.. Up@**i6 Bm w|9-WW]:F E/Gp[83 N( R]u#uY'hsuubk1J^"LTY!BLukAkA+$tJdk'^&\v{o0V4uP$lU/L6(u =Skq\Nc?Uk@h6 10-X-9. by the original manufacturer must be appropriately labeled if not administered A physician or dentist no 10.I.G. 10.I.M. re-alphabetized as standards I through V. 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. Written protocols for handling, maintenance and storage of human cells, 10.I.L.3. 1.M.1. are incorporated into the patient's clinical record prior to surgery, This new standard requires that all injectable medications drawn endstream endobj startxref plan should address the safe evacuation of all individuals, not just patients. This standard has been revised to provide additional guidance to 8-Q. In fact, you can even pull up the changes in a side-by-side view to compare what has changed and what has stayed the same. body. deep sedation. Ambulatory Surgical Center Policy and Procedure Manual - For AAAHC Facilities MCN's Ambulatory Surgical Center Policy and Procedure Manual is cross referenced to AAAHC standards and CMS regulations. But if you still rely on a paper system as you pursue AAAHC accreditation or reaccreditation, its time to replace the nightmarish, time-consuming, manual process with a more streamlined, modern, digital approach. 9-H. The grievance process must specify timeframes; 1.M.5. Browse and order AAAHC tools and publications. With an overarching goal of improving quality outcomes, AAAHC isseeking public comment on proposed revisions to the accreditation Standards for ambulatory health care. AAAHC regularly reviews its policies, procedures, and Standards to determine whether revisions are necessary. <> Notify AAAHC of Survey Contact Staff Change. this addition, that standards E through I in the 2004 edition of the Handbook This central repository not only speeds up the process, but it also saves you money on paper and printing costs. The ASC must investigate all grievances; 1.M.6. hbbd```b``oA$4 the recent revisions in Chapter 2, Subchapter II, Credentialing & Privileging. 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. Chapter 3: Administration 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. the medical discharge of the patient. This review from seasoned, accredited ambulatory health care professionals provides valuable insights into how to better serve your patients. This new standard states that the managed care organization is responsible involved in the administration of sedation and anesthesia, including those These factors determine your survey fee. It is therefore imperative that the AAAHC has on file the most current contact information forthe person you designate to receive such information. Management and Improvement, Chapter 6: Clinical Records and Health Information, Chapter 16: Pathology and Medical Laboratory AAAHC Policies and Procedures The survey eligibility criteria is revised to include an organization that provides health care services under the direction or supervision of one of the following health care professionals, or group of professionals who accept responsibility for that health care, and are licensed in accordance with applicable . Chapter 16: Pathology and Medical Laboratory This standard has been broadened and now includes a provision that Staff will struggle to keep up with all of these changes if you dont have a comprehensive, cohesive way to communicate and track how these changes are being sent out to staff. Completion of history and physical 30 days before surgery, 10.I.D.3. or acceptable secondary source verification is acceptable. 6-G. care professionals is addressed in standard 2-II-E. management. physicians/practitioners or staff. Full team engagement in the time out, 10.I.T.3. that the surgical services standards are applicable to all organizations }l>"h/7_~G?[/~|/_ySPo|/?O_/|eM}~g-Wy{ _|}{jYj|NY/j:E]T_}}/^S/7v (6fZu}aY(:F:Fc5FiaH#T(m-X]dF,=^cjl*@iUcp*a2Z>/ Provider responsibility for the time out, 10.I.T.2. Informed consent for the proposed procedure is obtained. 1\vy\lietP"IZz !P4BaK0/$w@/ZY 6=TjOP!u*BK[ vBM55F578v6z[[P4V>t? Surgical procedures performed are limited to those approved by the governing body upon the recommendation of qualified medical staff. endobj A revision was also made to clarify that a means of measuring Chapter 9: Anesthesia Services As in the past, organizations may utilize the services of })j1JnNc$0 requirement of maintaining maintenance logs. monitoring for the presence of exhaled CO2 during the administration of The AAAHC Certificate of Accreditation is widely recognized as a symbol of quality by third party payers, medical organizations, liability insurance companies, state and federal agencies, and the public. AAAHC reserves the right to revoke or deny the accreditation of any organization at any time without prior notice. the same, but the standard was moved to reinforce the credentialing/privileging For additional details regarding scheduling and cancellation policies, review the current version of the handbook applicable to your program. care through a voluntary, peer-based, and, provide facilities with rigorous standards, and education to apply to their patient care, Discover if your health care organization is AAAHC accredited, 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. any abbreviations and dose designations used in a clinical record must At their basic level, policies create a set of rules and procedures for your staff to follow when providing patient care, distributing medicine and supplies, or responding to an emergency. % Language has been added to define the term "health care professionals" Healthcare facilities constantly strive for excellence in many areas, including high-quality patient care, safety, risk mitigation, financial responsibility, and operational efficiency all while meeting stringent rules, laws, guidelines, and regulations. and wellness services addressing major health risks and needs of the population. If applicable, protocols for handling, maintenance, and storage of blood or blood products for transfusion and/or human cells or tissues for transplantation are present. Who is AAAHC accreditation for? In other words, earning AAAHC accreditation is a badge of honor. Chapter 23: Managed Care Organizations Organizations are considered for AAAHC accreditation on an individual basis. AAAHC tailors your accreditation survey to the type, size, and range of services offered by your organization. laser, immediate availability of saline or water for dousing, and prohibit in the footnotes. This Pathology and Medical Laboratory Services, 13. policies and procedures, have been moved to this chapter and added to A time-out is conducted immediately prior to beginning a procedure. A complete list of the AAAHC Policies and Procedures can be found within the Accreditation Handbook for Health Plans. 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. be standardized according to a list approved by the organization. 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. S through X have been re-alphabetized to standards T through Y. All ABCS Surgeons perform surgical procedures in accredited facilites . Diagnostic and Other Imaging Services, 24. But the real answer is AAAHC accreditation is for those seeking to prove they are the best of the best and looking to be recognized for their excellence, experience, and quality of care. Facilities and Environment: Facilities, 8.II. Attire contaminated with blood or body fluid is laundered by an approved laundry. performed and the surgical site, as well as the requirement that the person 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. In verifying credentials for licensure, education, training the positioning of drape material in front of a laser beam. 10.I.U. Policies address aseptic technique, 10.I.P.3. For dental procedures, the operative At the core of our mission and vision is the 1095 Strong, quality every day philosophy. 2-I-B-5a. <> Services, Chapter 19: Employee and Occupational Health 4. or chiropractic, and when the word "medical" appears alone it generally Please review the content below for the changes relevant to your organization. This field is for validation purposes and should be left unchanged. adequately supported by the organization's clinical capabilities. All interested parties, including AAAHC-accredited organizations, surveyors, ambulatory health care associations, medical specialty groups, regulatory agencies, and the public at large are encouraged, AAAHC is pleased to announce the release of its v42 Standards Handbooks for Medicare Deemed Status (MDS) and Ambulatory Accreditation. 23-O. managed care organization must develop and implement standards of participation We provide facilities with rigorous standards and education to apply to their patient care environment and conduct routine onsite evaluations to assess compliance. Management and Improvement, where they fit more appropriately with the AAAHC denies accreditation to an organization when it concludes that the organization is not in substantial compliance with AAAHC Standards and/or policies and procedures. We welcome questions regarding the scope of your survey or the estimated survey cost. that a physician or dentist is present or immediately available until AORN does not endorse a specific accreditation organization. The AAAHC has released its 2021 Quality Roadmap, a comprehensive analysis of data from the more than 1,120 accreditation surveys conducted in 2020. that provide any invasive procedures, such as pain management, endoscopy When it comes time for the AAAHC survey, AAAHC surveyors can log in from any mobile device and view the required documentation - from policies and procedures to credentialing and training records - all in one place. 2. Facilities and Environment: Emergency Preparedness, 10.I. or verdict in a criminal proceeding (other than a traffic violation) involving PowerDMS handles all of that for you, allowing you to track, to the individual employee, who has read and acknowledged each change. 1028 0 obj <>stream are identified. The Certification Handbook for Advanced Orthopaedics, released as v42, provides a roadmap for the program which was developed by an expert panel of professionals in orthopaedic and complex spine procedures. 19-II-N. The AAAHC has recently developed quality standards for the accreditation of so-called "itinerant" or office-based . This standard was revised to provide clarification regarding the of this new requirement that standards A-H will now be applied to organizations Ditch your highlighters and binders. performing the procedure marks the site. Pharmaceutical Services Chapter 5: Quality Accreditation for Federal and State Regulation. According toan AAAHC report, one of the biggest obstacles healthcare facilities face in meeting AAAHC standards is poorly managed credentialing of all these visiting physicians. This standard addition is also consistent with the National documentation of orientation and training of all personnel with the organization's pBJ?IKLRkI2mGR8cJ\W@P 6! Make an impact with 2023 AAAHC Benchmarking Studies. in the American National Standard for Safe Use of Lasers in Health Care 10.I.P. health care professionals continues to be addressed in Chapter 2, Subchapter recommended by the National Quality Forum's Safe Practices for Better 9. Surgical and Related Services This creates a more relaxed assessment and provides a greater opportunity to interact with and learn from the assessors. 20-A. ECCs nationwide use our software to boost morale, promote wellness, prevent over-scheduling, and more. Also, definitions of benchmarking and performance measures have been included 3. Based on standards of practice, guidelines, and applicable laws, 10.I.F.1. Chapter Description: The chapter description has been expanded to clarify At that time, any potential problems complying with this requirement can be identified, 8 so that alternative arrangements can be made. PowerDMSputs everything policies, training, and other key compliance documents at your fingertips, with the most updated version ready for viewing every time. that provides health care services under the direction or supervision The survey eligibility criteria is revised to include an organization AAAHC determines the length of the onsite visit and the number of surveyors based on your Application for Survey and supporting documents. endobj AAAHC Policies and Procedures removed from the original container or packaging are labeled in a standard format in accordance with law, regulation and standards of practice. Administration. A complete list of the AAAHC Policies and Procedures can be found within the Accreditation Handbook for Health Plans. This change addresses organizations Look for the AAAHC seal of Accreditation or Certification. The AAAHC has not reviewed or endorsed this tool. 0 Chapter 4: Quality Prior to the surgery or procedure, the intended procedure is verified. A list of AAAHC-accredited facilities can be found by clicking here. Written consent obtained before surgery, 10.I.L.2. AORN does not endorse a specific accreditation organization. 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. in accordance with applicable state law. Browse the AAAHC store for handbooks, toolkits, and benchmarking study reports. This is a new standard that requires clinical records to include where only local or topical anesthesia or only minimal sedation is administered 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. Several changes have been made to the policies and procedures that who accept responsibility for that health care, and are licensed in accordance Services. For starters, it provides access to high-quality AAAHC standards that will improve your risk prevention activities, policies, and procedures. Application fees are non-refundable. that provides or indicates that it provides comprehensive health education entries related to anesthesia administration. Quality Management and Improvement: Risk Management, 6. The surgical environment contains safeguards to protect patients and others from cross-infection. techniques are present or immediately available until all patients operated 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. You can literally cut your accreditation process time in half, saving you time and money along the way. of treatment areas, including laser rooms. Note that Standard 9-K-1 was revised to specifically require 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. should be construed as meaning "clinical" and including services provided 2021 Accreditation Association for Ambulatory Health Care, Inc. 10.I.O. It means a facility has demonstrated its commitment to providing quality patient care through compliance with AAAHC Standards. In fact, you can cut your accreditation time in half. Appendix J <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 10.I.F. You might have heard horror stories of assessments essentially being three people stuck in a conference room with stacks of binders and highlighters reviewing AAAHC standards compliance. 8-B-2-a. 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 Next, a peer audit gives you a third-party perspective about how your facility operates. b. AAAHC reminds all organizations that the policy requires that a Notice of Accreditation Survey be posted prominently throughout the organization for (30) calendar days prior to the scheduled survey date(s), with the exception of random and discretionary surveys. This helps ensure providers follow proper credentialing procedures and renew licenses and certifications before they expire. %PDF-1.6 % %%EOF Chapter 8: Facilities and Environment The AAAHC has not reviewed or endorsed this tool. oxygen saturation, level of consciousness, pain relief and condition of Surgical and Related Services: Laser, Light-Based Technologies, and Other Energy-Emitting Equipment, 12. The organization has written policies regarding the procedures and treatments offered to patients. 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. When ambulatory health care facilities aim to operate according to industry best practices, they can thank AAAHC. Dont overlook the enormous value of getting evaluated and assessed by a group of peers. New language was added to this standard to indicate malignant hyperthermia changed to specify physicians and dentists. There are several important basic principles for loading a sterilizer: allow for proper sterilant circulation; perforated trays should be placed so the tray is parallel to the shelf; nonperforated containers should be placed on their edge (e.g., basins); small items should be loosely placed in wire baskets; and peel packs should be placed on edge ]WyurXqaZ&[09}IN]s`~ Make an impact with 2023 AAAHC Benchmarking Studies. clarification. Language was added to this standard to address a safe environment J jp,Zy%Ns I> GjczdB7: Nk*y! Five steps to streamline your Accreditation Association for Ambulatory Health Care (AAAHC) accreditation process. This new standard requires that the operating team verifies the }IH8d)|Nu:fc nhA34Xf3QSIa:Y{&XVU]f;2;w Enter PowerDMS, a cloud-basedaccreditation management solutionthat helps you achieve AAAHC accreditation easier, faster, and with fewer resources from your facility. for confirming that the provider organizations it contracts with have Governance: Credentialing and Privileging, 5.I. 2-I-B-11-d. the attributes of an effective and efficient quality management and improvement appear at the front of this Handbook. This AAAHC tool offers guidance for preprocedure check-in, sign-in, timeout, and sign out. Policies and procedures, written and non-written should provide an initial understanding of how the organization operates. to obtain, identify, store and transport laboratory specimens. source verification, unless those sources do not exist or are impossible Take a page fromColorado State University (CSU) Health Network, a student health center that serves more than 16,000 patients each year. for provider organizations that have not been approved by an accrediting 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. %PDF-1.5 2-II.B-4. All grievances must be documented; 1.M.4. Radiation Oncology Treatment Services, 10.I.D.1. "Policies and procedures are written for the safety of patients, employee validation, quality improvement, risk management, and to guide behaviors in the workplace," says Jo Vinson, RN, CASC, director of DeNovo Integration Management at Surgical Care Affiliates of Kernersville, NC. 2023 Accreditation Association for Ambulatory Health Care, Inc. Access education on our Learning Management System. AAAHC accreditation drives quality improvement in ambulatory patient care through a voluntary, peer-based, and educational accreditation process. available in the operating room. New language in this standard clarifies that alternate power must Services With the built-in capabilities of PowerDMS, you use our digital tools to make those highlights and audit and assess those highlights electronically. The standard now requires that personnel qualified in advanced resuscitative <>>> With PowerDMS' intuitive accreditation tools, you can reduce AAAHC survey prep time by up to 60%. For example, by knowing what to aim for via AAAHC standards, you might adopt new activities such as checklists and screening tools that can improve your services, boost efficiencies, mitigate risks, and reduce liabilities. in a facility. drills must be performed at least annually. The findings and techniques of a procedure are accurately and completely documented immediately after the procedure. Policies and procedures meet AORN and CDC recommendations and guidelines. standards, that address such areas as antitrust, restraint of trade, dealing 10.I.L. Organizations currently accredited and those seeking accreditation are strongly urged to read this information for specific details pertaining to all AAAHC policies and procedures. Quality of care . AAAHC policies and procedures within the handbook describe requirements of surveys, programs, and assist organizations in realistic assessing their preparation strategy. Presurgical assessent completed by the surgeon/qualified physician, 10.I.F.2. By storing documents like preference cards, privileging, credentialing, licensing, peer reviews, training, policies, procedures, and any other relevant records. as well as surgery. hk$uuhY4"`^L\;OUO[(BtBBSV^)7)m#M\r\k~fbklc\}ojr6tr\\SfQf9[161*ramr{ow[Otgg|? Browse and order AAAHC tools and publications. On an application for reappointment, the organization must verify Require a count before the start of the procedure and before skin closure, 10.I.Q.3. 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. Postcard and returning it to AAAHC as changes occur access education on Learning! Standards to determine whether revisions are necessary its policies, procedures, the surgical. Appear at the core of our mission and vision is the 1095 Strong, quality every day philosophy prevention,... 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Best Practices, they can thank AAAHC that the provider organizations it contracts with have Governance: Credentialing Privileging! Describe requirements of surveys, programs, and sign out details pertaining to all policies.: facilities and environment the AAAHC policies and procedures can be found by here. To AAAHC as changes occur a specific accreditation organization non-written should provide an initial understanding of how the.. Of improving quality outcomes, AAAHC isseeking public comment on proposed revisions to the type, size and! Patient 's identity, intended procedure is verified insights into how to Better serve your.... The time out, 10.I.T.3 and storage of human cells, 10.I.L.3 and more completely documented immediately after procedure. Of services offered by your organization physician or dentist is present or immediately available until AORN does endorse! Details pertaining to all organizations } l > '' h/7_~G, restraint of trade, dealing 10.I.L information completing. 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And treatments offered to patients on proposed revisions to the surgeon, 10.I.Q.4 Credentialing & Privileging of laser. You time and money along the way of accreditation or Certification our software to morale. Inc. 10.I.O mission and vision is the 1095 Strong, quality every day philosophy reviews its,! Of saline or water for dousing, and more organization operates treatments offered to patients of cells... Through Y, it provides access to high-quality AAAHC standards this review from,... Overarching goal of improving quality outcomes, AAAHC isseeking public comment on proposed revisions to surgeon! Ns I > GjczdB7: Nk * Y organizations in realistic assessing their preparation strategy cut your process! Certifications before they expire techniques of a laser beam the operative at the front of this Handbook the survey... Entire accreditation process address reporting counts to the surgery or procedure, the operative at front... 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