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Revisions to the Accreditation
Handbook for Ambulatory Health Care Since the 2004 Edition
Chapter 2: Governance
2-I-C-3. This standard was expanded to require notice to the AAAHC within
30 days of any government investigation, criminal indictment, guilty plea
or verdict in a criminal proceeding (other than a traffic violation) involving
directly or indirectly the organization or any of its officers, administrators,
physicians/practitioners or staff. An organization's duty to provide this
information continues during the entire accreditation process
2-II.B-4. This standard was revised to clarify that a CVO used to verify
credentialing information does not need to be accredited itself, although
accreditation is one way of demonstrating the quality of the CVO. The
revision also clarifies that when an organization uses a CVO for credentials
verification, it is the expectation that the CVO has performed primary
source verification, unless those sources do not exist or are impossible
to verify.
Chapter 3: Administration
3-A. (13, 14, 15) Based on the redefining of Chapter 5 (see below), these
standards, that address such areas as antitrust, restraint of trade, dealing
with inquiries from governmental agencies, attorneys and the media and
documentation of orientation and training of all personnel with the organization's
policies and procedures, have been moved to this chapter and added to
the overall responsibilities of the organization's administration.
Chapter 4: Quality
of Care Provided
4-E. This new standard requires that the organization establish procedures
to obtain, identify, store and transport laboratory specimens. Note with
this addition, that standards E through I in the 2004 edition of the Handbook
have been re-alphabetized as F through J.
Chapter 5: Quality
Management and Improvement
Chapter 5 has been substantially rewritten to help organizations understand
the attributes of an effective and efficient quality management and improvement
system that links peer review, the quality improvement program and risk
management.
Language has been added to define the term "health care professionals"
as used in Chapter 5 to include all clinical and administrative personnel.
Also, definitions of benchmarking and performance measures have been included
in the footnotes.
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Subchapter
I - Peer Review
This subchapter has been revised to provide better definition of how
to develop an effective peer review program. New standards have been
added to reinforce the importance of integrating the peer review program
into the recredentialing process for health care professionals, including
physicians, dentists, nurse practitioners, certified registered nurse
anesthetists and physician assistants. In addition, standards from
Chapter 7, Professional Improvement (see below), related to professional
competence and skill have been moved to this subchapter to emphasize
the linkage between the peer review process and the quality of performance
of health care professionals.
Subchapter II - Quality Improvement Program
This subchapter has been rewritten to help organizations understand
the relationships between the overall quality improvement (QI) program,
quality improvement studies and performance benchmarking. In addition,
the standards have been revised and expanded to describe the specific
characteristics of an effective quality improvement program and the
essential steps to developing QI studies.
Subchapter III - Risk Management
This subchapter has been revised to reflect the importance of a quality
risk management program for an accreditable organization. A key component
of the revision to this subchapter is the new requirement that the
risk management program elements will now be evaluated as full standards
rather than permissive guidance. In addition, some of the elements
have been moved to more appropriate chapters of the Handbook (for
example, chapters on Governance and Administration).
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Chapter 6: Clinical Records and Health Information
6-G. This standard has been broadened and now includes a provision that
any abbreviations and dose designations used in a clinical record must
be standardized according to a list approved by the organization. This
revision is consistent with the National Quality Forum's Safe Practices
for Better Health Care.
6-J. This standard has been expanded to ensure that the presence or absence
of allergies and untoward reactions to drugs or materials must be verified
at each patient encounter and updated whenever new allergies or sensitivities
are identified.
Chapter 7: Professional Improvement
The standards previously stated in this chapter have been moved to other
chapters in the Handbook, including Governance, Administration, and Quality
Management and Improvement, where they fit more appropriately with the
requirements of these areas.
Chapter 8: Facilities and Environment
8-B-2c. The footnote for this standard has been expanded to reinforce
that the four required emergency drills per year should be appropriate
to the organization's activities and environment and may include drills
for medical emergencies, tornados, earthquakes, bomb threats or other
emergencies.
8-Q. New language in this standard clarifies that alternate power must
be available in all patient care areas and where emergency services are
provided.
Chapter 9: Anesthesia Services
9-H. This is a new standard that requires clinical records to include
entries related to anesthesia administration. Note that with the addition
of this new requirement that standards A-H will now be applied to organizations
involved in the administration of sedation and anesthesia, including those
where only local or topical anesthesia or only minimal sedation is administered
and standards H through U in the 2004 edition of the Handbook have been
re-alphabetized as standards I through V.
9-L-1 and 9-M. Both of these standards were revised to clarify that a
physician or dentist must be present, not merely immediately available,
until a patient's medical discharge, and that personnel qualified in advanced
resuscitative techniques are present until the patient has been physically
discharged.
9-V. Additional language has been added to this standard that recommends
monitoring for the presence of exhaled CO2 during the administration of
deep sedation. A revision was also made to clarify that a means of measuring
body temperature must be readily available during the administration of
general anesthesia.
Chapter 10: Surgical Services
10-I. Consistent with the revision to standard 9-M, this standard was
revised to clarify language requiring that personnel qualified in advanced
resuscitative techniques be present until all patients operated on that
day have been physically discharged.
10-L-4. New language was added to this standard requiring that authorized
persons in the surgical or treatment rooms must decontaminate hands, as
recommended by the National Quality Forum's Safe Practices for Better
Health Care.
10-R. This standard has been revised to provide additional guidance to
ensure that organizations use a process to identify the procedure being
performed and the surgical site, as well as the requirement that the person
performing the procedure marks the site. For dental procedures, the operative
tooth may be marked on a radiograph or a dental diagram.
10-S. This new standard requires that the operating team verifies the
patient's identity, intended procedure, the correct surgical site and
that all equipment and devices necessary for the procedure are immediately
available in the operating room. It also requires the operating surgeon
is personally responsible for ensuring that all aspects of this verification
have been satisfactorily completed immediately prior to the beginning
of the procedure. This standard addition is also consistent with the National
Quality Forum's recent report. Note that with this new standard that standards
S through X have been re-alphabetized to standards T through Y.
10-T. Former Standard 10-S now requires that the staff perform repeated,
frequent assessments of the patient's blood pressure or hemodynamic status,
oxygen saturation, level of consciousness, pain relief and condition of
the procedure site, upon completion of the patient's procedure until medical
discharge.
10-X-9. The revision to this standard requires accredited organizations
to document that laser maintenance logs are current, rather than the previous
requirement of maintaining maintenance logs. This change addresses organizations
that lease their laser equipment, noting that the responsibility for maintaining
the log may belong to the contractor, but it is the responsibility of
the organization to check and document that log.
Chapter 16: Pathology and Medical Laboratory
Services
Chapter 16 has been split onto two subchapters for clarity and consistency.
Subchapter I is applicable to organizations that meet the Clinical Laboratory
Improvement Amendments (CLIA) of 1988 requirements for waived tests, while
subchapter II is applicable to organizations that provide laboratory services
that require certification under the Clinical Laboratory Improvement Amendments
of 1988.
Chapter 19: Employee and Occupational Health
Services
19-II-N. This new standard addresses travel medicine, requiring that these
services are appropriate to the needs of the employees and patients and
adequately supported by the organization's clinical capabilities. It also
addresses what should be included in travel medicine programs and services,
as well as for entries in clinical records.
Chapter 23: Managed Care Organizations
23-N. This new standard specifies that the managed care organization works
to improve the health status of its members with chronic conditions.
23-O. This new standard states that the managed care organization is responsible
for confirming that the provider organizations it contracts with have
been reviewed and approved by a recognized accrediting body or that the
managed care organization must develop and implement standards of participation
for provider organizations that have not been approved by an accrediting
body.
AAAHC
Policies and Procedures
Several changes have been made to the policies and procedures that
appear at the front of this Handbook. Organizations currently accredited
and those seeking accreditation are strongly urged to read this information
for specific details pertaining to all AAAHC policies and procedures.
Appendix E
This Appendix is updated to reflect the recent revisions of Chapter 5:
Quality Management and Improvement.
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