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Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Quality in College Health: Achieving AAAHC Accreditation.

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Presentation on theme: "Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Quality in College Health: Achieving AAAHC Accreditation."— Presentation transcript:

1 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Quality in College Health: Achieving AAAHC Accreditation American College Association Annual Meeting June 4, 2010 Margaret Spear, MD and Ray Grundman, MSN, FNP

2 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. As a result of attending this program, attendees will be able to: 1.List the benefits of achieving accreditation. 2.Describe the actions necessary to prepare for accreditation. 3. Describe the accreditation survey process. Behavioral Objectives

3 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Behavioral Objectives 4. Describe the core standards which a college health service must meet to achieve AAAHC accreditation. 5.Describe the adjunct standards that a college health organization must meet in order to achieve AAAHC accreditation.

4 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Accreditation  To give official authorization/approval  To provide with credentials  To recognize as conforming with a standard  To consider or recognize as outstanding

5 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standards  A rule, principle or measure  Established by an authority  Having recognized or permanent value

6 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standards – Clinical/Medical AMA, AAFP, ACIP, ACP, etc

7 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standards – Non-clinical, other  Higher Ed – CAS, NASPA  Standards for health promotion in higher education (ACHA/NASPA)

8 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Benefits of accreditation  Public and community confidence  External recognition  Professional and organizational growth and improvement  Intangibles

9 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Public and community confidence  Demonstrates the commitment of the organization to provide quality services  Report card measure gives the community a basis for comparison  Increases the organization’s competitive edge  Can be used in internal and external marketing

10 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. External Recognition  May expedite third party reimbursements  May enhance risk management profile and reduce insurance payments  May be recognized by purchasers and health care networks as a benchmark for quality  May satisfy certain regulatory requirements for licensure or certification

11 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Professional Improvement  Encourages staff professionalism  Facilitates internal quality improvement  May promote staff morale and organizational self-esteem  Can help organizational stability  May assist in recruiting top quality staff  Survey itself is a learning opportunity

12 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Intangibles  The true value is in the consultative and educational process the precedes and follows the survey itself  The intense self-analysis, peer review and consultation ultimately help and organization to improve services and programs for its customers

13 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. So you want to be accredited…

14 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. AAAHC

15 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. The Joint Commission

16 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. About AAAHC... Private, independent, not for profit Established in 1979 Exclusive focus on ambulatory health care Over 4,800 currently accredited organizations Two subsidiary companies  AAAHC Institute for Quality Improvement  Healthcare Consultants International

17 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. What is distinctive about AAAHC?  Peer-based accreditation program  Nationally recognized standards  325 volunteer surveyors – nurses, physicians, dentists, administrators  Governing structure – 17 member organizations. ACHA is a founding member.  Consultative & educational process

18 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. AAAHC philosophy  Discovery…………….vs. inspection  Consultation… vs. prescription  Collaborative…………vs. dictatorial

19 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Types of organizations that seek accreditation  ASCs  Student health centers  Office-based surgery centers  Immediate/urgent care centers  Occupational health  Radiation oncology  Diagnostic imaging centers  Behavioral health - new  Medical group practices  Medical home - new  Military health care facilities  Lithotripsy centers  Dental groups  Community health  Endoscopy centers  Podiatry practices  Indian Health centers

20 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Decision Factors  Fit  Cost  Community  Politics

21 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. The process of accreditation  Decision making  Choose the agency  Involve staff  Review standards and other materials  Establish a realistic timetable  Design a plan to prepare

22 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. The decision to do it  College/University administration  Health services staff  Resources, time and money

23 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Preparation  Review standards and other materials  Professional development for accreditation leader  Build on consensus/choose team  Establish timetable  Overview assessment

24 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Preparation  Accreditation team tabletop exercise  Detailed gap assessment  Develop needed policies/procedures  Modify processes as needed

25 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Mock accreditation  You and your staff  Colleague from accredited center  Consultant – private or from accreditation agency

26 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Accreditation process  Pre-survey application/submission  Site survey  Post survey decision-making  Decision

27 © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. ACHA 2010 Annual Meeting AAAHC Core Standards 2010 Appropriate portions of the core standards (Chapters 1-8) are applied to all organizations seeking accreditation.

28 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. AAAHC core standards (cont.)  Rights of patients  Governance  Administration  Quality of care

29 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. AAAHC core standards (cont)  Quality improvement  Clinical records  Infection control  Facility

30 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients An accreditable organization recognizes and respects the basic human rights of patients.

31 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients Standards address two key areas:  How patients are treated as people  Ensuring that patients are fully informed

32 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients How patients are treated as people Standards A, B, C, E:  Respect, consideration, and dignity  Privacy  Confidentiality  Participation in decision making

33 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients Ensuring that patients have information regarding their rights and responsibilities Standards F.1, G, H:  Informed of all rights (including A-E)  Responsibilities, e.g., provide complete and accurate information; follow prescribed treatment plan; be respectful of all  Right to change providers and participate in decision making

34 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients Ensuring that patients are fully informed regarding their care Standards D, F.7, F.8:  To the degree known, complete information concerning diagnosis, evaluation, treatment and prognosis  Right to refuse participation in clinical and device trials  Advance directives

35 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients Ensuring that patients have information regarding their provider(s) Standards F.3, F.9, I, J:  Services available at the organization  Credentials of health care professionals  Accurate marketing/advertising/practice promotion  Absence of professional liability insurance coverage

36 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients Ensuring that patients have information regarding policies & procedures Standards F.4-6, K:  After-hours and emergency care  Fees and payment policies  Suggestions, complaints and grievances

37 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients Some items surveyors will look for, observe, review  Privacy practices, HIPAA,FERPA  Related P&Ps, including whether they match information provided to patients, student employees  Patient handouts, instructions, consent  Web site, Health Promotion, e-Medicine

38 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 1: Rights of Patients Common problems  Privacy: check-in/registration, exam room curtains, conversations, waiting area  U. registration name vs. “known as”  Consent form for procedures with written post-procedure instructions

39 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 2: Governance An accreditable organization has a governing body that sets policy and is responsible for the organization.

40 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standards address two areas:  Subchapter I General requirements for an organization and its governing body  Subchapter II Credentialing and privileging of health care professionals Chapter 2: Governance

41 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standards A and B – Governing body  Legally constituted entity  Sets direction, future planning, budgets  Ensures adequate, appropriate facilities and personnel  Establishes structure and policies  Ensures evaluation of the quality of care including patient safety  Reviews and responds to legal, ethical matters Chapter 2, Subchapter I: General Requirements

42 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standard B (cont.): Governing body:  Ensures effective internal communication  Maintains financial health and control  Approves and ensures compliance with all vendor and payor contracts  Ensures compliance with all applicable local, state and federal laws, rules, regulations and guidelines Chapter 2, Subchapter I: General Requirements

43 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standard B (cont.): Governing body:  Develops a program of risk management  Ensures safe environment of care including infection control and patient safety  Establishes processes to address incidents and reportable events Chapter 2, Subchapter I: General Requirements

44 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Some items surveyors will look for, observe, review  Legal entity (e.g. Land Grant, Charter)  Mission, goals, objectives, long- / short-range planning  Current organizational chart  Governing document (e.g., Operating Manual)  Meeting minutes: governing body, committees, staff  Procedures for ensuring continued compliance with all applicable state/federal regulations  Scope of clinical activities  Contracts/agreements with outside entities  Adverse incident processes Chapter 2, Subchapter I: General Requirements

45 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Common problems  Poorly documented or missing Governing Body, committee meeting minutes  Outdated P&Ps  Lack of Policy dealing with minors  Incomplete processes for identification, reporting, analysis and prevention of adverse incidents Chapter 2, Subchapter I: General Requirements

46 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Credentialing An accreditable organization:  Establishes minimum training, experience and other requirements (credentials) for its health care professionals  Establishes process to review, assess and validate required qualifications  Carries out the review, assessment and validation according to its own stated process Chapter 2, Subchapter II: Credentialing and Privileging

47 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standard A  Requires an established process, applied in uniform manner, including mechanisms for credentialing, reappointment, granting of privileges, suspending or terminating privileges, and appeal of these decisions (Sample application form in “Forms” section of Handbook) Chapter 2, Subchapter II: Credentialing and Privileging

48 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standard B Required characteristics of the process  specific criteria; expeditious processing of applications  establishes the information needed for credentialing and privileging  acceptable verification processes  reapplied at least every three years  ongoing monitoring and documentation of current licensure, DEA, insurance, etc. Chapter 2, Subchapter II: Credentialing and Privileging

49 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Privileging An accreditable organization:  Determines clinical services offered  Determines required qualifications for privileges to provide each service  Establishes process for evaluating applicant’s qualifications and approving, modifying or denying any or all requested privileges Chapter 2, Subchapter II: Credentialing and Privileging

50 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standards C, D, E, F  Privileges granted for specific time period  Notification of appropriate authorities re: suspension/termination, as required by state/federal law  Independent process of credentialing and privileging  Allied health care professionals Chapter 2, Subchapter II: Credentialing and Privileging

51 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Some items surveyors will look for, observe, review  Credentialing/privileging policies and procedures  Collaborative practice agreement, if State required, for advanced practice nursing  Policies/procedures for notifying licensing and/or disciplinary bodies; NPDB  List of approved procedures that may be performed at the organization and how privileges are granted Chapter 2, Subchapter II: Credentialing and Privileging

52 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Common problems  Lack of verification of credentials either currently or hires prior to accreditation  Credentials and Privileges granted for specific time period  Query of / reporting to NPDB  Review of credentialing records separate from employment/personnel records Chapter 2, Subchapter II: Credentialing and Privileging

53 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 3: Administration An accreditable organization is administered in a manner that assures the provision of high-quality health services and that fulfills the organization’s mission, goals, and objectives.

54 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 3: Administration Standards address three (3) areas:  Administrative responsibilities for the orderly and efficient management of the organization, including assessment of patient satisfaction  Personnel policies, including employee orientation and training  Occupational health care for staff

55 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 3: Administration Standard A: Administrative responsibilities 1.Enforcement of policies 2.Employment of qualified management personnel 3.Planning (strategic positioning) 4.Documentation of compliance

56 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 3: Administration Standard A (cont.): 5. Protecting assets 6. Implementing fiscal controls 7. Ensuring internal communication 8. Purchasing and maintaining materials, supplies, equipment, services

57 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 3: Administration Standard A (cont.): 9.Establishing lines of authority, responsibilities, accountabilities 10. Controlling organization documents 11. Ensuring data security 12. Maintaining health information system 13. Infection Control, Patient Safety, and Exposure Control Plan

58 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 3: Administration Standard A (cont.): 14. Avoiding antitrust, restraint of trade 15. Dealing with external inquiries Standard G: Assessing patient satisfaction

59 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 3: Administration Some items surveyors will look for, observe, review  How the Governing Body has delegated administrative responsibility  Clinic and Department P & Ps  Employee Health & Safety addressed including OSHA-300 Form  Intra-department communication  Patient satisfaction results

60 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 3: Administration Common problems  Lack of or ill-defined Governing Body directives and actions  Lack of or ill-defined delineation of roles, responsibilities, accountabilities  Decentralized, uncoordinated services  Staff communication / in-service education

61 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided An accreditable organization provides high-quality health care services in accordance with the principles of professional practice and ethical conduct, and with concern for the costs of care and for improving the community’s health status.

62 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Critical chapter: Here, the organization demonstrates that all health care providers, and the organization overall, provide high-quality health care.

63 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Critical chapter (cont.) Integrates many of the core and applicable adjunct standards:  Ch 1 – Effective communication with patients  Ch 2 – Governance, including credentialing and privileging  Ch 3 – Personnel  Ch 5 – Quality management and improvement  Ch 6 – Clinical records  Ch 8 – Facility safety

64 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Standards focus on five areas:  Health care professionals  Documented evidence that high-quality care is provided  Mechanisms for referrals, consultations and transfers  Cost of care  Methods of communication with patients

65 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Standards A-D, F, G – Health care professionals  Training and skills, sufficient number  Practice in ethical, legal manner  Credentialing and privileging  Peer review and quality improvement  Clinical records documentation

66 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Standards E, H, I – Documented evidence that high-quality care is provided  Effective communication with patients  Review and update of medications  Appropriate and timely diagnosis  Treatment consistent with diagnosis  Patient satisfaction

67 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Documented evidence that high-quality care is provided (cont.) Standards H, I  Lab specimens or biological products  Follow-up of abnormal or significant lab or radiologic findings

68 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Standards F.2, J, K – Mechanisms for referrals, consultations and transfers  Facilitate referral or consultation for patients  Transfer agreement, providers with admitting/similar privileges at the hospital, or detailed procedural plan submitted to AAAHC

69 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Standard L – Cost of care  Care is appropriate  Absence of duplicative diagnostic procedures  Appropriate treatment frequency  When possible, using less expensive resources  Ancillary services consistent with patient needs

70 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Standard M –  Methods of communication with patients  Communicating in the language or manner used by the patient

71 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Some items surveyors will look for, observe, review  Review of credential records, employee records, clinical records  Peer review activities  Quality improvement activities  Policies and procedures  Interpreters, use of telecommunications technology or other means of communication  Written transfer agreement with local hospital, if applicable

72 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 4: Quality of Care Provided Common problems  Lack of interpreter services  Confusion regarding review and update of medications  Organization’s responsibility for ensuring a process for lab / radiologic follow-up  Referrals not well documented  Transfer agreement OR providers with admitting or similar privileges  Costs of care not addressed

73 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. In striving to improve the quality of care and to promote more effective and efficient utilization of facilities and services, an accreditable organization maintains an active, integrated, peer-based program of quality management and improvement that links peer review, quality improvement activities and risk management in an organized, systematic way. Chapter 5: Quality Management and Improvement

74 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Note: The intent of this chapter is that administrative and clinical personnel be involved in the quality management and improvement activities of the organization. Chapter 5: Quality Management and Improvement

75 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Three subchapters:  I – Peer Review  II – Quality Improvement Program  III – Risk Management Chapter 5: Quality Management and Improvement

76 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Standards focus on three areas:  What elements must the peer review process contain?  Who must participate?  What happens to the results? Chapter 5, Subchapter I: Peer Review

77 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Elements of the peer review process Standards C, E, I:  Ongoing monitoring of important aspects of care, individually and in the aggregate  Ongoing data collection and periodic evaluation to identify trends affecting patient outcomes  Ongoing monitoring of continued licensure, certification Chapter 5, Subchapter I: Peer Review

78 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Who must participate? Standards A, B, D, H:  Health care professionals understand, support and participate  At least two health care professionals  Participation in development and application of criteria used to evaluate care  In educational activities, with access to up-to-date information Chapter 5, Subchapter I: Peer Review

79 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. What happens to the results? Standards A, F, G, H  Integrated into quality management and improvement program  Reported to the governing body  Used as part of privileging process  Maintain professional competence Chapter 5, Subchapter I: Peer Review

80 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Some items surveyors will look for, observe, review  Peer review policies and procedures  Records of peer review activities  Documentation that peer review information is provided to the governing body as part of the quality improvement and credentialing/privileging activities Chapter 5, Subchapter I: Peer Review

81 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Common problems  Monitoring of licensure – expired credentials  Chart review is a component, but not sufficient  Involvement of at least two health care professionals  Individual and aggregate practitioner performance data Chapter 5, Subchapter I: Peer Review

82 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter II: Quality Improvement Program An accreditable organization maintains an active, integrated, organized, and peer-based quality improvement (QI) program.

83 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter II: Quality Improvement Program Subchapter describes components of the quality improvement program that addresses:  Clinical, administrative and cost-of-care performance issues  Actual patient outcomes, i.e., results of care, including safety of patients

84 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter II: Quality Improvement Program Standard A The QI program must: 1.Be written 2.Identify persons responsible 3.Involve at least one physician 4.Have goals and objectives 5.Identify appropriate problems

85 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter II: Quality Improvement Program Standard A (cont.) The QI program must: 6.Identify activities, including internal/external benchmarking 7.Be linked to peer review and risk management 8.Be evaluated annually for effectiveness 9.Require that findings be reported to governing body and elsewhere in organization as appropriate

86 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5: Subchapter II, Quality Improvement Program Standard B Written reports of QI activities include the following elements: 1.Purpose 2.Performance goal 3.Description of data to be collected 4.Evidence of data collection 5.Data analysis – frequency, severity, sources of problem(s)

87 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter II: Quality Improvement Program Standard B (cont.) Written reports of QI activities include: 6.Comparison of current performance vs goal 7.Corrective action(s) 8.Re-measurement 9.Additional corrective actions if necessary 10.Communication/reporting of findings

88 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter II: Quality Improvement Program Standard C External benchmarking must include:  Performance measures  Collection and analysis of performance data  Changes in performance  Improvement over time  National benchmarks  Link to QI studies  Reporting of findings

89 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter II: Quality Improvement Program Some items surveyors will look for, observe, review  A Quality Plan and a Quality Program  Activities: projects, studies  Program Committee meeting minutes  Reporting mechanism(s) to G.B.  Education programs resulting from projects, studies

90 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter II: Quality Improvement Program Common problems  Topics to study  All Quality Monitoring (QA) and no Quality Improvement (QI)  Lack of documenting data collection  Internal and External Benchmarking  Reporting of findings

91 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter III: Risk Management An accreditable organization develops and maintains a program of risk management, appropriate to the organization, designed to protect the life and welfare of an organization’s patients and employees.

92 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter III: Risk Management Five major areas:  Governing body and designated person(s)  Comprehensive risk management program  Non-staff in patient care areas  Review of clinical records/policies  Education for all staff

93 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter III: Risk Management Standard F:  Periodic review of clinical records/policies Standard G:  Education in risk management provided to all staff and affiliated persons

94 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter III: Risk Management Some items surveyors will look for, observe, review  Policies and procedures  Activities  Complaints, Incident reports, Adverse events  Staff education  Committee minutes

95 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 5, Subchapter III: Risk Management Common problems  No designated person(s)  Lack of policies addressing:  Dismissal from care  Incapacitated professional  Impaired professional  Visitors  Periodic review of policies/clinical records

96 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 6: Clinical Records and Health Information An accreditable organization maintains clinical records and a health information system from which information can be retrieved promptly. Clinical records are complete, comprehensive, legible, documented accurately in a timely manner, and readily accessible to health care professionals.

97 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 6: Clinical Records and Health Information Standards focus on five areas:  Clinical record policies  Appropriate and accurate documentation  Review and authentication  Transfer of information when patients are treated elsewhere  Informed consents and advanced directives

98 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 6: Clinical Records and Health Information Standards A - F – Clinical record policies  Clinical records system  Patient identification  Format and sequence  Confidentiality and security  Retention and retirement

99 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 6: Clinical Records and Health Information Some items surveyors will look for, observe, review  Policies and procedures  Interview clinical records personnel  Clinical records – paper or electronic  Selected by surveyor (selection cannot be delegated to organization)  At a minimum, within last 12 months  Within past 36 months involving deaths, unplanned transfers, litigation, and unplanned outcomes/incidents

100 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 6: Clinical Records and Health Information Common problems  Appropriate patient identification  Timely charting  Multiple visits / admissions or complex and lengthy record  Documentation of medications, allergies, untoward reactions; updated at each visit  Records stored off-site

101 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 7 Infection Prevention & Control, and Safety  An accreditable organization provides health care services while adhering to safe practices for patients, staff and all others. The organization maintains on- going programs designed to 1) prevent and control infections and communicable diseases, and 2) to provide a safe and sanitary environment of care.

102 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 7 Infection Prevention & Control, and Safety Divided into two sub-chapters Sub-I. Infection Prevention & Control Sub-II. Safety

103 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 7 Infection Prevention & Control, and Safety Infection Prevention & Control  use nationally recognized guidelines (WHO, CDC)  approved, monitored by Governing Body  sharps injury prevention program  adequate surveillance techniques  Isolation or transfer of patients with communicable disease

104 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 7 Infection Prevention & Control, and Safety Safety  Elements of safety program meet or exceed local, state, federal safety requirements  Person or committee assigned responsibility  Drugs/biologicals expiration date

105 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 7 Infection Prevention & Control, and Safety Some items surveyors will look for, observe, review  Nationally-recognized infection control guidelines  Surveillance program  Person or committee assigned responsibility  Single-use drug vials, P&P on proper use of needles/syringes  I.C. consultant available

106 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 7 Infection Prevention & Control, and Safety Common problems  Co-ordination with University Safety and Assurances or Environmental Services, housekeeping/maintenance  Lack of staff with specialized training  Lack of space for patient isolation

107 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment An accreditable organization provides a functionally safe and sanitary environment for its patients, personnel and visitors.

108 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Components of “safe and appropriate environment”  OPERATIONAL: Activities, care processes, protocols  Policies and procedures  PHYSICAL: Design and construction  Accepted standards of care  Building codes and standards

109 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Facility regulations Standards A.1 - 4: Facilities must conform to local, state and federal regulations, building codes, and fire prevention requirements including "periodic" inspections. Existing facilities should already be in conformance with applicable codes, as demonstrated by a current occupancy permit.

110 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Facility regulations Standards B.1 - 4:  Appropriate portable fire extinguishers  Illuminated emergency exit signs  Emergency exit pathway lighting  Fire-protected stairwell exits

111 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Rules Standards H, I & J:  No smoking  Avoid hazards  Accommodate disabled individuals

112 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Accommodate disabled individuals

113 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Accommodate disabled individuals

114 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Policies / Systems Standards C, D, E & F: Emergency preparedness – non-medical:  Written emergency & disaster preparedness plan  Ongoing staff education/training  Evacuation of patients & others at risk  Support of external/community health emergency / disaster preparedness  Quarterly disaster preparedness drills per year, with written evaluations of each  One (minimum) cardiopulmonary resuscitation technique drill

115 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Policies / Systems Standard G: CPR-trained staff available during patient occupancy times  Trained in use of cardiac and all other emergency equipment

116 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Specific standards of care Standards B-7, M, Q  Parking identification  Patient food and snacks: need-based, handled per health department requirements  Emergency equipment for patient care: accessible and maintained

117 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Some items surveyors will look for, observe, review  Physical inspection: clean, orderly, free of hazards?  Licenses, inspection reports  Sterilization and infection control records  Records of emergency drills conducted  Emergency and disaster preparedness plans  Current “tags” on fire extinguishers  Exit sign locations and types

118 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Chapter 8: Facilities and Environment Common problems  Clean / dirty separation  Food service per health dept. requirements  Alternate power  Construction for privacy  Quarterly drills of disaster plan - not just fire

119 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.

120 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. AAAHC Core Standards 2010  Appropriate portions of the core standards (Chapters 1-8) are applied to all organizations seeking accreditation

121 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Adjunct Chapters  Anesthesia services  Surgical and related services  Pharmaceutical services  Pathology and medical laboratory services  Diagnostic and other imaging services  Behavioral health services  Teaching and publication activities  Other professional and technical services  Health education and health promotion

122 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Adjunct Chapters (cont.)  Research activities  Overnight care and services  Occupational health services

123 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Adjunct Chapters (cont.)  Immediate/urgent care services  Emergency services  Radiation oncology treatment services  Managed care organizations  Lithotripsy services  Medical home

124 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Common Requirements  Staff training and credentials  Space – adequate and appropriate  Policies, procedures  Communication

125 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Health Education and Health Promotion  Clinical health education/secondary prevention  Public health/campus community primary prevention  Resources  Evidence based  Learning objectives

126 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Anesthesia Services  Local/topical only  Credentialed, qualified staff  Consent  Environment and quality of care

127 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Surgical Services  Minor procedures/suturing  Appropriate record keeping  Functional, sanitary environment  Credentialed, qualified staff  Consent

128 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Pharmaceutical Services  Compliant with federal and state regulations  Safety and security – especially injectables  Sound prescribing and good patient education  Controlled substance issues

129 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Pathology and Medical Laboratory Services  CLiA waived tests only  CLiA labs – more complex testing  Accuracy, timeliness, thorough policies, procedures  QA/QC

130 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Diagnostic and other Imaging Services  Radiation safety for staff and patients  Correct site identification  Storage and retention  Timely authentication and review

131 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Other Professional and Technical Services  Physical therapy  Nutrition counseling  EMS  Optometry  Other

132 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Behavioral Health Services  Psychological counseling  Alcohol and other drug counseling  Psychiatry  Privacy

133 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Teaching and Publication Activities  Health science students  Undergraduate/graduate  Contracts  Governing body oversight of publications

134 Standards © 2010 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved. Research Activities  IRB approval  Patient rights and welfare  Governing body oversight


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