Transcription of Accreditation Handbook
1 16 For AmbulatoryHealth CareAccreditationHandbook5250 Old Orchard Road, Suite 200, Skokie, IL 60077 Accreditation Handbook forAmbulatory Healthcare, or parts thereof, may not bereproduced in any form or byany means, electronic ormechanical, including photocopy,recording or any informationstorage and retrieval systemnow known or to be invented,without written permission from AAAHC, except in the case of brief quotations embodied in critical articles or reviews. For further information, contactthe President & CEO, AAAHC, at the address above. References are made through-out this Handbook to the NFPA101 Life Safety Code, 2000 Edition. Both are registeredtrademarks of the National FireProtection Association, Quincy,Massachusetts.
2 The pronouns used in thishandbook were chosen for ease of reading. They are not intended to exclude references to either gender. OUR MISSIONIMPROVING HEALTH CARE QUALITY THROUGHACCREDITATION 2016 Accreditation ASSOCIATIONforAMBULATORYHEALTHCARE, AAAHC, our aim is to help improve the quality of care that accredited organizations provide to theirpatients, and the efficiency and effectiveness of how these organizations operate. We accomplish this with a consultative, educational approach to Accreditation that centers on a triennial on-site survey and onresources that provide continuous opportunities for building performance excellence. One such resource is the Accreditation Handbook . Each year we create versions of the Handbook that are customized to reflect distinctions among the types of practices that our Accreditation programs 2016, the version you are holding (or reading electronically) is intended for primary medical or dental careorganizations and for surgical/procedural care organizations that are not surveyed by AAAHC for MedicareDeemed Status.
3 This is also the right publication for an organization that owns and operates at least 10 sitesof (non-surgical) care, and seeks Accreditation as a network. These organizations should begin review of ourpolicies and procedures at the Network Accreditation Programtab. For ASCs that do participate in the AAAHC Medicare Deemed Status Program, we have developed theAccreditation Handbook for Medicare Deemed Status Surveys. The content of the individual AAAHCS tandards remains the same in both books, but our Standards and the CMS Conditions for Coverage have been interwoven and some policies and procedures are unique to Medicare Deemed Status smaller surgical organizations, there is the Accreditation Handbook for Office-Based Surgery.
4 While theseorganizations must meet the same AAAHC Standards, this publication includes surveyor review guidelinesintended to offer additional support in understanding our expectations for how an organization with a smaller staff and a less complex organizational structure can demonstrate compliance with the Handbook is designed as a tool for self-assessment. Review the relevant Standards and evaluate howyour organization puts them into practice. The worksheets identical to those used by surveyors can beuseful in performing a mock survey. The self-assessment process may reveal best practices of which youwere unaware or situations in which you are performing an important activity, but neglecting to document itor to evaluate its outcome.
5 Remember that measurement drives improvement but only if you review andcompare the data and take corrective action when AAAHC surveyors visit your organization, they are not only evaluating your compliance with theStandards; they are bringing a collegial and consultative point of view to create a focused and helpful surveyexperience. But the on-site survey that serves as your organization s three year check-up is not the onlytime we want to hear from you. Your comments on proposed changes to the Standards, your questionsabout individual Standards, and your feedback on our process and resources is a valuable component ofour own self-assessment. Thank you for your support of our Chapman, MBAS tephen A. Martin, Jr., PhD, MPHB oard ChairPresident and CEOF oreword 2016 Accreditation ASSOCIATIONforAMBULATORYHEALTHCARE, gratefully acknowledge the efforts of the AAAHC Board of Directors, the Standards and SurveyProcedures Committee, and the Health Plan Advisory and Survey Procedures CommitteeMeena Desai, MD, Chair Villanova, PADavid M.
6 Shapiro, MD, Vice-Chair Tallahassee, FLMarshall Baker, MS, FACMPEB oise, IDEdward Bentley, MDSanta Barbara, CAKaren Connolly, RNBirmingham, MIGerald Fleischli, MDCreswell, ORChristine Gallagher, RN, BSN, CNORS alinas, CARichard Gentile, MDYoungstown, OHSusan Griffin, MSMT ampa, FLMargaret Haecherl, RN, MS, CNOR, PHNN ashville, TNDavid Hamel, DDSM arysville, KSSandra Jones, CASC, LHRM, CHCQM, MBA, MSMDade City, FLLawrence S. Kim, MD, AGAFLone Tree, COGayle Lowe, RN, MBAS acramento, KYBonnie Petty, FNP, MPH, CPNPT hendara, NYBeverly K. Philip, MDBoston, MADenise Ricketts-Goombs, RN, MPH, MBAW ellington, FLKenneth Sadler, DDS, MPA, FACDW inston-Salem, NCDennis Schultz, MDFranklin, WIEdwin Slade, DMD, JDDoylestown, PABenjamin Snyder, FACMPESan Diego, CAScott Tenner, MD, FACG, MPHB rooklyn, NYNancy Jo Vinson, RN, CASCK ernersville, NC Staff LiaisonsMona Sweeney, RNAssistant Director, Accreditation ServicesMichon Mayfield, MHAD irector, Accreditation Services 2016 Accreditation ASSOCIATIONforAMBULATORYHEALTHCARE, to Readers.
7 Using this HandbookThe 2016 edition of the Accreditation Handbook forAmbulatory Health Carehas been developed to communicate AAAHC policies and procedures, toassist organizations in realistically assessing their compliance with AAAHC Standards, and to providetools and resources to help health care organizationsimprove. The Standards are presented with rating checklists to provide an easy way to track the results of self-assessment. The compliance ratings are defined as:SC Substantially Compliantindicates that the organization s current operations are acceptable andmeet the Partially Compliantindicates that a portion of the item is acceptable, but other areas should Non-Complaintindicates that the organization soperations in the relevant area do not meet the Not Applicableindicates that the Standarddoes not apply to the organization (only present inadjunct chapters).
8 Following the chapters are tools that parallel thoseused by surveyors while on-site, and additionalresources that may be to Readers: Maintaining contact with AAAHCFrom time to time, AAAHC uses e-mail to distributeimportant information affecting accredited rely on each accredited organization to make sure that these communications get to the relevantindividual by designating a Primary Contact. If your organization changes its Primary Contact for Accreditation , please follow the instruction below to be sure your organization continues to receiveimportant and timely information from contact information changes on facility letterhead,signed by your organization s Administrator or ChiefMedical Officer via e-mail, fax, or mail as Mail: AAAHC Accreditation Services, 5250 OldOrchard Road, Suite 200, Skokie, IL 60077 Notice of a change should include the name of thenew Primary Contact, his/her job title, phone number,and e-mail address.
9 Changes to the Primary Contactare not accepted over the to Readers 2016 Accreditation ASSOCIATIONforAMBULATORYHEALTHCARE, 2016 Accreditation ASSOCIATIONforAMBULATORYHEALTHCARE, Policies and Application of the Applicable version of the Comments and suggestions about the Outpatient of New York Office-Based Surgery Accreditation Process: Getting 1: Confirm that your organization meets survey eligibility 2: Identify the types of surveys available ..6 Early Option Initial Accreditation Re- Accreditation Survey ..7 3: Apply for an on-site survey ..8 Obtaining an Application for A note about 4: Payment and Survey Scheduling.
10 9 Survey Cancellation 5: Pre-Survey Responsibilities and Responsibilities of the applicant Responsibilities and preparation of the surveyor or survey chairperson ..10 Public posting of Notice of Accreditation Accreditation Process: During the The survey Surveyor conduct during the Additions to the survey team ..11 The on-site Organizations with multiple service Request to survey sub-units of an Organizational or Functional Integration ..13 Concluding the survey experience ..13 The Accreditation Process: After the Accreditation decision and Term of Accreditation .
