OR Manager August 2022 - 24

BY JUDITH M. MATHIAS
Tips to prepare for AAAHC accreditation
AMBULATORY
he Accreditation Association for
Ambulatory Health Care (AAAHC)
has been accrediting ambulatory
healthcare facilities, including ambulatory
surgery centers (ASCs), for more
than 40 years, with some 6,100 accredited
organizations.
T
A top philosophy of AAAHC is " 1095
Strong, " which emphasizes the importance
of integrating quality practices
throughout a facility's 1,095 days of its
3-year accreditation term.
AAAHC standards are nationally recognized
and developed by expert panels,
and surveyors have extensive experience
in the ambulatory setting from
both the clinical and business sides.
Among the survey types are:
* initial accreditation
* early option
* reaccreditation
* interim-full/focused
* random
* discretionary
* special.
Surveys are tailored to a specific organization
and include:
* number of operating and procedure
rooms
* number of providers
* patient volume
* complexity of services offered
* previous survey deficiencies
* reported significant changes
* number of satellites.
AAAHC standards consist of eight
core chapters applicable to all organizations,
no matter the type. They range
from patient rights and responsibilities
to governance to administration to infection
prevention to clinical records.
At
the Ambulatory Surgery Center
Association 2022 conference in Dallas
in April, Jan Kleinhesselink, BSHM, RN,
CPHQ, chief quality officer at Lincoln
Surgical Hospital, Lincoln, Nebraska,
and a AAAHC surveyor, along with David
M. Shapiro, MD, CHC, CHCQM, CHPRM,
24
OR Manager | August 2022
LHRM, anesthesiologist,
chair-elect of the
AAAHC Board, and a
AAAHC and Medicare
surveyor, presented a
workshop on Preparing
for AAAHC Accreditation.
Some of the highlights
follow.
SURGERY CENTERS
cilities, says Kleinhesselink. She adds
that it is okay for a facility to have a
policy that says something like: " During
the time you are in our facility we will
provide life-saving measures. "
Jan Kleinhesselink,
BSHM,
RN, CPHQ
Chapter 1: Patient rights and
responsibilities
" One of the first things we check when
we come into your organization is that
you have written patient rights and responsibilities, "
says Kleinhesselink.
Each organization has to have a process
by which patients receive their
written rights and responsibilities before
they receive any care. This can be done
at the physician's office or on admission
to the facility.
Included in this chapter are:
* patient privacy and security policies
that comply with the Health Insurance
Portability and Accountability
Act and Health Information Technology
for Economic and Clinical Health
Act
* policies on cell phones and service
animals
* multi-lingual patient information.
" We want to see curtains being
pulled around the patient and an admission
process during which the patient's
privacy is not violated at all, " notes
Kleinhesselink. Patients also need to
know how to file complaints and grievances-the
process and the follow-up,
she says.
Another part of this chapter concerns
advanced directives. " You need to ask
your patients whether they have an advance
directive, " says Kleinhesselink.
Generally, when people say their facilities
do not honor advance directives,
they mean they are not going to honor
" do not resuscitate " orders at their faChapter
2: Governance
Chapter 2 says: " An accreditable organization
has a governing body that sets
policy and is responsible for the organization. "
Dr
Shapiro notes, " You can't get
through any kind of presentation
about AAAHC
or any accrediting organization
without hearing
the term 'governing
body' because everything
rolls up to the
governing body. It's the
place where the buck
stops. "
David M.
Issues the governing
Shapiro, MD,
CHC, CHCQM,
CHPRM,
LHRM
body deals with include:
* mission, goals, and objectives
* long-range plans
* adequate and appropriate facilities
and personnel.
The governing body also is legally
responsible for the operation and performance
of the organization, including:
* bylaws
* policies and procedures
* financial management
* legal and ethical matters
* compliance to AAAHC standards.
All the items for which the governing
body is responsible are highlighted and
documented in this chapter, says Dr
Shapiro.
The only way surveyors have to verify
the actions of the governing body is to
look at the governing body minutes, he
says, adding: " So be very diligent about
how you keep your minutes. "
Dr Shapiro recommends making a
list of everything done by the governing
body every single year, possibly using
www.ormanager.com
http://www.ormanager.com
OR Manager August 2022

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