Patients typically are asked about . *. Point of Care testing lab controls documented and control solution labeled & dated. *expiration and open dates. Although the accreditation survey is evaluative, AAAHC emphasizes the educational and consultative benefits of accreditation. American Association for Accreditation of Ambulatory Surgery Facilities 1. AAAHC surveyor(s) conduct the survey. Appropriate storage of boxes and pt care items: * Not directly on floor. * 18" clearance from sprinkler head. * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping. * Volume of combustible material is not stored in large quantity as to create a fire hazard. No equipment or shelving is blocking access to panels. Patient Bedside: *. AAAHC Grows Surveyor Talent with Intensive Training and Development August 17, 2022 Press Releases AAAHC Calls for 2022-23 Bernard A. Kershner Innovations in Quality Improvement Award Submissions August 9, 2022 Press Releases AAAHC Unveils Winners of the Bernard A. Kershner Innovations in Quality Improvement Award August 2, 2022 Press Releases A key at the end of this checklist (page 8) explains the If being used are being tested for leakage of currents. Elements m.1-M.6 are addressed. The AAAHC Quality Roadmap provides a thorough analysis of data from previous surveys conducted using current Standards, and helps support ongoing quality improvement throughout your accreditation cycle. Fire doors are not blocked or propped and when closed there is positive latching. aaahc survey checklist 2020. 2023 Accreditation Association for Ambulatory Health Care, Inc. Access education on our Learning Management System. They are available in other languages for non-English speaking patients. 2023 Accreditation Association for Ambulatory Health Care, Inc. Access education on our Learning Management System. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. They are also posted in the facility waiting room in a font size legible to most. AAAHC offers tools, resources, and education throughout your pre-survey planning. Click here to access the notice and additional instructions. * Patient information is not discussed in public areas. * Labels and PHI are obliterated before discarding in the trash. You may also use the wildcard character, %, if you are not sure of the exact organization name. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. . . Achieving Accreditation is an interactive, immersive event designed to help you learn and prepare for your AAAHC survey while developing a deeper understanding of AAAHC Standards. Conduct a self-assessment with AAAHC Standards, and develop an action plan to address any gaps. All Rights Reserved. Daily checklist completed for temperaturesCorrect temp observed: Food & drink, 36-45( FCorrect temp observed: Medications, 36-46( FCorrect temp observed: Specimens, 36-46( FCorrect temp observed: Blood, 34-43( FCorrect temp observed: Freezers, (32( FOnly medications in medication refrigeratorOnly food in food refrigeratorOnly specimens in Waiting room is separated from other patient care areas. Client / Site Conducted on Date Prepared by Location Address Personnel Survey Readiness Checklist/Audit/Tracer DESCRIBE THE UNITS RESPONSE TO YOUR AUDIT Manager or delegate attended survey? Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked. AAAHC will inform you of the accreditation decision. The Joint Commission Life Safety & Environment of Care Document List and Review Tool 2021 Page 2 of 17 Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation STANDARD - EPs C See Legend Document / Requirement Yes No NC NA IOU LS.01.01.01 Buildings serving patients comply w/ NFPA 101 (2012) All patients are informed in the pre op call of the requirement for a responsible adult to drive them home and stay with them for the first 24 hours. Initial accreditation surveys apply to organizations currently not accredited by AAAHC and have been providing services for at least six months before the onsite survey, or organizations with expired AAAHC accreditation that are again seeking accreditation through AAAHC. Lead Aprons: Not torn, Clean, hung properly, have proper labeling for current year, have been checked by a radiation physicist annually, report can be provided: There is a process for cleaning of aprons between cases utilizing a product that will not harm the integrity of the aprons. LIFE SAFETY CODE DOCUMENTATION REVIEW CHECKLIST Hospitals and Nursing Homes New Mexico - LSC 101, 2012 Edition . Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, 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, AAAHC Hosts Winter Conference to Highlight Excellence in Ambulatory Care, AAAHC Announces New Board Officers and Directors, engaging a wide range of ambulatory health care experts to develop, review, and revise Standards, assessing organizations against these Standards and their own policies and procedures, creating tools to support continuous quality improvement, has been providing health care services for at least six months before the onsite survey, excluding organizations seeking accreditation through an, is either a formally organized and legally constituted entity that primarily provides health care services, or a sub-unit that primarily provides such services within a formally organized and legally constituted entity that may be, but need not be, health related, 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, is licensed by the state in which it is located, if the state requires licensure for that organization, unless the organization is applying for a survey that will be used to obtain licensure in a state that recognizes AAAHC accreditation for this purpose, provides health care services under the direction of one of the following health care professionals; (these individuals or groups of professionals must accept responsibility for the health care provided by the organization and must be licensed in accordance with applicable state laws), Doctor of dental surgery or dental medicine (DDS/DMD), Advanced practice registered nurse (APRN) practicing in compliance with state law and regulation, Licensed clinical behavioral health professional in a behavioral health setting, shares the facilities, equipment, business management, and records involved in patient care among the members of the organization, operates in compliance with U.S. Your AAAHC account manager will help you navigate the requirements to remain in good standing. Click on " join " and create an account. Please login to access everything you need to review onsite surveys and control the workflow. Please enter in a search term to continue. Achieving Accreditation is an interactive, immersive event designed to help you learn and prepare for your AAAHC survey while developing a deeper understanding of AAAHC Standards. 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference, 8th Annual Health IT + Digital Health + RCM Conference, 29th Annual Meeting - The Business & Operations of ASCs, Digital Health + Telehealth Virtual Event, 580+ ASCs with total joint replacements | 2023, State-by state breakdown of 2022's 183 new ASCs, 510 of America's 'Best' ASCs in 2023: Newsweek, UPMC, surgeon to pay $8.5M for allegedly performing multiple complex surgeries at once, ASCs' reimbursement woes: What's worrying leaders in 2023, Physician specialties with the happiest marriages, Amazon, USPI & Optum: 4 biggest ASC deals in February, Private practice 'not feasible' for young physicians, says Rush University surgeon, 15 things to know about the 3 biggest ASC chains, Rancho Mirage Hospital to spend $156M on cardiology ASC, pavilion expansion. Staff know what to do if a patient presents with chemical contamination-Isolate patient from other/facility, call 911. Prescription pads are kept in a locked location. AAAHC provides tools and resources designed to assist ambulatory health care organizations in the pursuit of ongoing quality improvement. No outer shipping carton boxes in patient care areas. Adding the AAAHC accreditation tasks to your to-do list can feel overwhelming. Achieving Accreditation is an interactive, immersive event designed to help you learn and prepare for your AAAHC survey while developing a deeper understanding of AAAHC Standards. You have just activated six months of membership as a pre-accredited practice. Fire extinguishers have been inspected monthly. * Random sampling extinguisher tags checked. L&R's Compliance Binders come bundled with pre-printed tab dividers, each containing the appropriate compliance code for your accreditation standards. No expired medications or supplies(check all treatment areas which staff stock). Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, 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, AAAHC Hosts Winter Conference to Highlight Excellence in Ambulatory Care, AAAHC Announces New Board Officers and Directors. Gas cylinders on stretchers show more than 1/4 full. AAAHC expert faculty will discuss the new CMS QSO-22-07 requirements impacting your organization. Does physician caseload correlate with burnout? Eyewash stations: Inspection logs are present and up to date. Able to promptly deliver requested logs and materials required for review. Surveyors found that the areas with the highest deficiencies included: Infection prevention/safe injection practices Taken together, these resources support accelerated readiness with a seamless and enriching experience. Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, 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, AAAHC Hosts Winter Conference to Highlight Excellence in Ambulatory Care, AAAHC Announces New Board Officers and Directors. This chapter was expanded considerably in the 2006 handbook, now containing 15 specific categories, or "characteristics" that an "accreditable . AAAHC recently published a detailed report on the accreditation or reaccreditation standards with the best and worst compliance, titled AENEID, which is available for no charge online. "Scrub the hub"-vial tops wiped and hubs scrubbed prior to administration(alcohol:15 secs, CHG 30 secs). Policies and procedures have been developed, approved and implemented for imaging services. Medication errors account for 3.5 million physician office and 1 million emergency room visits per year. AAAHC Survey Notice for members and employees January 14, 2022 Over-the-Counter (OTC) COVID-19 Diagnostic Tests Effective January 15, 2022 - Coverage for over-the-counter (OTC) at-home COVID-19 diagnostic tests January 24, 2022 2021 Massachusetts Schedule HC 2021 Massachusetts Schedule HC Information October 13, 2021 Open Season Page AAAHC Publishes Medication Reconciliation Benchmarking Study Findings. The state health department and Medicare Ombudsmen contact information are also included in the document. i Medication . An upcoming AAAHC survey can serve as a wake-up call for a healthcare center to get its documentation in order, but waiting until the last minute is risky. Copyright 2023 Becker's Healthcare. AAAHC determines the length of the onsite visit, the number of surveyors needed, and the survey date and fee. Stay1095 Strong and register for the complimentary self-paced module, Immediate Implementation: CMS COVID-19 Vaccination Tracking. The National Committee for Quality Assurance. For additional questions regarding the pandemic on your operations and services, please contact us. No expired items. * Random sampling of supplies and equipment checked. For more detail on these and all 24 standards, visit the AAAHC Web site at www.aaahc.org. Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, 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, AAAHC Hosts Winter Conference to Highlight Excellence in Ambulatory Care, AAAHC Announces New Board Officers and Directors. She has worked as an ASC Surveyor for AAAHC since 2007. The AAAHC has released its 2021 Quality Roadmap, a comprehensive analysis of data from the more than 1,120 accreditation surveys conducted in 2020. Phone: (888) 275-7585. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. Staff know what numbers to call codes and where to find code carts and resources. Is unit's PI project data posted and current, Staff can speak to current PI projects and goals, High Alert Meds with independent double check. AAAHC determines the length of the onsite visit and the number of surveyors based on your Application for Survey and supporting documents. . Code Carts: * Locked and marked with then first drug to expire. * Checked per policy. * Include defibrillator check. * Extra locks kept secured. * All supplies & drugs that are on the inventory list are on the cart. *. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. Pre treatment of instruments is observed prior to delivery to CS: Instruments are in good working order and not bent or broken: Instruments requested for surgery are present prior to patient entry to OR: Instruments have all paramenters met and are confirmed by OR staff prior to patient entry to OR: Steris recycle bins and Biohazard instrument disposal bins are not overflowing: CS staff are wearing proper attire to transport dirty instruments: CS department equipment is in proper working order and/or work orders in progress: Vendors are adhering to policies and procedures with regard to requests: AAAHC accreditation is current and posted for viewing in a public area. All Rights Reserved. 2023 Accreditation Association for Ambulatory Health Care, Inc. Early Option Surveys (EOS) apply to organizations not accredited by AAAHC, meet AAAHC eligibility criteria, and have been providing services for fewer than six months. Patient care supplies: * Not expired, damaged, soiled. The type of background material to be gathered Interim surveys are conducted for AAAHC-accredited organizations and for which oversight is required to assess ongoing compliance with the accreditation Standards. TJC HRSA Accreditation and Patient-Centered Medical Home Recognition Initiative. Patient satisfaction information is usually gathered using a survey through which patients have the chance to give current feedback, according to the AAAHC. Please enter in a search term to continue. Browse and order AAAHC tools and publications. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. This commitment to ongoing education and quality improvement demonstrates survey readiness not only on the day of the survey but all 1,095 days of the accreditation term. * Patient conversations private, Please provide examples of NC(include picture if appropriate). Discretionary surveys are conducted for cause, when concerns have been raised about an accredited organizations continued compliance with AAAHC Standards. survey EP for non long term care facilities. Medication rooms are clean and uncluttered. Refrigerators: Temp-track accessible. The 2022AAAHC Quality Roadmap provides our annual review and analysis of Standards compliance, reflecting data from surveys conducted in 2021-2022. 1095 Strong Journey. All solutions are labeled at the bedside. The 2017/2018 Accreditation Handbook for Medicare Deemed Status Surveys will include the revised Physical Environment Checklist (PEC) from 2016 to reflect adoption of the 2012 editions of NFPA 99 and 101 by CMS and the new CMS requirements for emergency preparedness. Existing Users. The coronavirus (COVID-19) pandemic continues to change the way the health care industry addresses safety and infection control and prevention. Scan this QR code to use this paper checklist on your smartphone or tablet or We offer a unique peer-based review process founded on a collaborative, consultative, and educational approach. How does staff know the KSC provider is qualified to take care of a patient's needs? Staff understand the incident command structure/talk about drills and what we do an after action debrief for? The Credentialing Department performs background check & verifies professional medical licenses through the State Board of Medical Examiners, DPS, & DEA Registration How do patients know their KSC provider is qualified to take of their needs? The patient is asked about AD and a copy is obtained if the patient has an executed AD. Staff can state, identify, find or know about the following: * KP Learn * UO Reporting: Culture of Safety and Reporting * Red Rule/2 Patient Identifier * Look alike-Sound alike drugs * Policies and Procedures. Email: hrsaaccreditation@jointcommission.org. Browse and order AAAHC tools and publications. For all programs, depending on the survey type, survey activities will include the addition of a readiness checklist that addresses disaster preparedness and infection control and prevention. 1095 Learn, our AAAHC learning portal, delivers interactive and engaging education to refresh your knowledge and optimize your organizations quality practices. AAAHC SurveyLink ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE assisting ambulatory health care organizations improve the quality of care provided to patients Welcome to the AAAHC Staff Website! For additional details regarding scheduling and cancellation policies, review the current version of the handbook applicable to your program. Dosimetry badges are worn, testing has been completed quarterly and results are maintained. . To drive collaboration and help your team members improve the quality of care you provide, rely on AAAHC tools to stay accreditation ready. At the 19th annual Ambulatory Surgery Centers Conference in Chicago on Oct. 26, Gina Dolsen, RN, BSN, MA, vice president of operations for Blue Chip Surgical Center Partners and an Accreditation Association for Ambulatory Health Care surveyor, provided eight tips to help ASCs ace their AAAHC survey. Including C-arms and U/S. Driven leader with 10+ years of experience in healthcare, events, philanthropy, and non-profits. COVID-19 Resources | AAAHC Final days for Early Bird: Register for Achieving Accreditation today! Life Safety Documentation Requirements Revision: 2; 7-28-17 Based on the 2012 edition of the Life Safety Code, for Ambulatory Surgical Centers Date Assessment: _____ We are facing the future together1095 Strong! Review infection control risk assessment and practices to ensure they align with CDC recommendations for managing COVID-19 Assess how much personal protective equipment is in stock and monitor potential alternatives in the marketplace Implement contactless vendor services to ensure vendors and staff are protected 3. COMPREHENSIVE SURGICAL CHECKLIST Blue = World Health Organization (WHO)Green = The Joint Commission - Universal Protocol 2016 National Patient Safety GoalsTeal = Joint Commission and WHO PREPROCEDURE CHECK-IN SIGN-IN TIME-OUT SIGN-OUT In Preoperative Ready Area Before Induction of Anesthesia Before Skin Incision However, there are many reasons why this is beneficial. Debrief of findings completed at end of mock survey? Linking and Reprinting Policy. $1,885.00. All Rights Reserved. We develop and support strong policies and procedures as they relate to our program Standards. Stay 1095 Strong and click here to register. The difference between a complaint and grievance is defined in the policy and procedure.There is a flow chart for the process and logs are maintained. Confidential Patient Information: Cannot be overheard or seen by unauthorized persons: * Computer terminals signed off when not in use. Staff using equipment are trained and checked annually for competency. 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. Medication is appropriately labeled. * Medication name * Medication strength * Initials of person drawing up medication * Date and time of draw * Expiration date and time(one hour from draw)