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Revisions to the Accreditation Handbook for Ambulatory Health Care since the 2008 Edition
Chapter 1 – Rights of Patients
C. The wording in this standard was modified to include specific language about release of patient information.
Chapter 2: Governance, subchapter I, General Requirements
B-11. The language in this standard was modified to require organizations to ensure that contracted services are provided in a safe and effective manner.
C. The requirement for notification to AAAHC of significant changes has been changed from 30 calendar days to 15 calendar days and requires organizations to report significant organizational, ownership, operational or quality of care events including criminal indictments, guilty plea or verdict in a criminal proceeding, as well as any change/event that negatively affects the public’s perception about the organization. The definition of “significant changes” is addressed in the Accreditation Policies and Procedures on page 12 of the Handbook.
Chapter 2 – Governance, Subchapter II,
Credentialing and Privileging
B-3b. This element regarding peer evaluation requires organizations to ensure that current competence is verified and documented.
B-3gv. This element was modified to remove the word “clinic” and add “medical group” and “other health care entity” as part of the list of entities that may have denied, suspended, limited, terminated or did not renew professional privileges.
B-4. This element was modified to clarify that
accreditation is one of the ways for the Credentials Verification Organization (CVO) to demonstrate capability and quality. The standard also stresses the organization’s responsibility to assess the capability and quality of the CVO. Therefore, organizations are not relying upon the CVO’s accreditation as the only means of ensuring the capability and quality of the CVO. In addition, the CVO is not required to be accredited.
B-5. This element was modified to clarify that education, training and experience, and peer evaluation are not part of the items to be verified at reappointment. The items listed in Standard 2.II.B-3c-g are required to be verified. Also included is the requirement that an application be completed as part of the reappointment process and that reappointment should occur every three (3) years, or more frequently if required by state law or organization policies.
B-7. This element was modified to include solo dentist practices and that reappointment should occur every three (3) years, or more frequently if required by state law or organization policies.
C. This standard was modified to include privileges granted based on qualifications and recommendations from qualified medical personnel.
Chapter 3 – Administration
A-12ai. This element was modified to further clarify the requirement for a link to the organization’s quality improvement program.
B. Standard A-15 has been combined with all the personnel requirements in Standard 3-B.
Chapter 4 – Quality of Care Provided
D. A new standard has been added that requires organizations to conduct ongoing, comprehensive self-assessment of the quality of care provided.
E. This standard was modified to clarify those items that demonstrate evidence of highquality health care.
F. Elements 4.D-12, 13-18 have become part of this new standard, to provide items that demonstrates an organization’s ability to facilitate accessible and available care that ensures patient safety.
G. Previously 4.E – This standard was modified to add the requirement of “timely” clinical record entries.
H. Previously 4.F – This standard was modified to include biological products.
M. Standard 4.L in 2008 has been moved to Chapter 8, Facilities and Environment, standard E as part of the organization’s emergency and disaster preparedness plans.
Chapter 5 – Quality Management and Improvement,
Subchapter II, Quality Improvement Program
B. This standard was revised to provide further clarity about the steps to follow when conducting quality improvement activities. Elements B-1 through B-7 are all replaced with new elements B-1 through B-10.
C-1. This element was modified to remove the word “may” to clarify that the benchmarking requirements are required.
Chapter 5 – Quality Management and Improvement,
Subchapter III, Risk Management
D, E. These new standards require organizations to focus on areas of patient privacy not previously addressed with respect to nonorganization staff and observers in patient care areas.
F. Previously 5.III.D – A revision was made regarding clinical record reviews to replace the word “conducts” with “requires.”
Chapter 6 – Clinical Records and Health Information
The chapter introduction was modified to include the requirement for "complete" clinical records.
I. This standard has been revised to further clarify the intent of the standard.
M. A revision was made to replace “clinical” personnel with “organization’s” personnel.
O, P. These standards have been replaced with the new standard 6.O to more clearly outline the requirement to obtain and transfer information when a patient has been treated outside the organization.
P. Previously 6.Q – This standard was revised to ensure that discussions with the patient also include proposed care or procedure in addition to surgery.
Chapter 8 – Facilities and Environment
A. The elements of this standard address compliance with appropriate local, state and federal requirements. Elements 8.A-5 through 8.A-9 are now part of the new standard B.
B. This standard requires organizations to ensure that their facilities comply with the following previous standards: 8.A-5 through 8.A-9, I, J, L.
E. Previously 8.D – This standard includes the previous standard 4.L and requires organizations to also address disaster preparedness in written emergency plans.
F. Previously 8.E – In addition to the requirement for four drills of the emergency and disaster preparedness plan, an organization must also complete a written evaluation of each drill, including any corrections or modifications to the plan.
G. Previously 8.F – This standard was revised to require the organization to have personnel that are trained in cardiac and all other emergency equipment, and to have these personnel in the facility to provide patient care during hours of operation.
H. Previously 8.G – This standard now prohibits smoking in the facility.
Chapter 9 – Anesthesia Services
B. This standard was revised to reinforce the need to grant privileges for supervision of anesthesia services.
F. This standard was revised to specify the appropriate health care professionals that may provide anesthesia and that they must be directly supervised by a physician or dentist who has been privileged for such supervision.
A definition of qualified health care professionals is also provided in the following footnote:
Other qualified health care professionals are qualified by virtue of education, experience, competence, professional licensure, state laws, rules and regulations. Other health care professionals must be approved for the administration of anesthesia by the governing body pursuant to Chapter 2.II.
H. This new standard requires all clinical personnel with direct patient contact to maintain skills in basic cardiac life support (BLS).
N. Previously 9.M – This standard was revised to provide further clarification of the requirements for personnel with ACLS training and their presence during hours of operation. In addition, the training must include “hands-on” airway management training and automated external defibrillator (AED) use during ACLS and PALS training and retraining.
P. This standard now includes the requirement that the organization have written policies in place for safe use of injectables and single-use syringes and needles.
R. Previously 9.Q and R – This standard was developed to clearly outline the requirements for organizations that administer agents known to trigger malignant hyperthermia.
V. This standard was revised to further reinforce Standard 9.F.
Chapter 10 – Surgical and Related Services,
Subchapter I, General Requirements
A new introduction has been added to provide clarity about the applicability of Chapter 10 and the use of various terms related to surgery, procedure and operation used throughout the Handbook.
E. This standard was modified to provide a specific timeframe for health histories and physical examinations.
I-1. This element was revised to provide further clarification of the requirements for personnel with ACLS training and their presence during hours of operation. In addition, the training must include “hands-on” airway managemen training and automated external defibrillator (AED) use during ACLS and PALS training and retraining.
J. This standard, previously part of 10.I.I, requires personnel trained in the use of emergency equipment and BLS in the facility when patients are in the facility. It also requires a physician or dentist to be present or immediately available by telephone when patients are physically present in the facility.
L. Previously 10.I.K – This standard was revised to replace “operation” with “procedure” and “provider” with “health care professional” to avoid limiting this standard to operations only and only to those operations that may be performed by physicians.
M-9. Previously 10.I.L-9 – This element was revised to replace “operation” with “procedure” to avoid limiting this standard to apply only to operations.
N. This new standard requires the organization to have policies addressing the reprocessing of single-use devices.
O. Previously 10.I.M – This standard was revised to require organizations to develop protocols regarding the use and administration of blood and blood products in the organization.
U. Previously 10.I.S – This standard was rewritten to require organizations to clearly describe the process, communication and documentation necessary to ensure appropriate monitoring to facilitate continuity of post-operative care.
Chapter 10 – Surgical and Related Services,
Subchapter II, Laser, Light-Based Technologies
and Other Energy-Emitting Equipment
This subchapter was modified to include any equipment used directly on a patient.
B-5. This element was revised to add “when necessary” to the requirement for protective eyewear.
B-9. This element was revised to require appropriate documentation of maintenance logs.
The following adjunct chapters have been renumbered based on services provided most often by accredited organizations. The chapters are ordered as follows:
Chapter 11 (previously 15) – Pharmaceutical Services
I. This is a new standard that requires the organization to have policies in place for safe use of injectables and single-use syringes and needles.
Chapter 12 (previously 16) – Pathology and Medical
Laboratory Services, Subchapter I, CLIA Waived Tests
D. This standard was revised to outline the requirements for for reviewing and reporting test results.
Chapter 12 (previously 16) – Pathology and
Medical Laboratory Services, Subchapter II, CLIA
Laboratories
D. This standard was revised to outline the requirements for reviewing and reporting test results.
Chapter 13 (previously 17) – Diagnostic and
Imaging Services
D-4. The revisions to this standard include additional safety aspects to the standard.
F. This new standard requires a process to identify the service to be performed and involve the patient in the process.
Chapter 14 (previously 12) – Dental Services
A new introduction has been added to provide organizations with criteria as to when the chapter will be applied.
N. This standard has been modified to require all clinical personnel with direct patient contact to maintain skills in basic cardiac life support (BLS).
Chapter 15 (previously 20) – Other Professional
and Technical Services
Chapter 16 (previously 24 – Health Education
and Health Promotion
Chapter 17 (new) – Behavioral Health Services
This new chapter was developed to provide standards that address behavioral health services.
Chapter 18 (previously 21) – Teaching and
Publication Activities
Chapter 19 (previously 22) – Research Activities
B. This standard was modified to specifically require that protocols be written.
Chapter 20 (previously 11) – Overnight Care
and Services
M. The language of this standard was modified to include the provision of refreshments and how food and refreshments are handled.
Chapter 21 (previously 19) – Occupational
Health Services
Chapter 22 (previously 14) – Immediate/Urgent
Care Services
L. This standard was revised to require all clinical personnel maintain skills in basic cardiac life support (BLS).
Chapter 23 (previously 13) – Emergency Services
J. This standard was revised to require all clinical personnel maintain skills in basic cardiac life support (BLS). Also, medical personnel with ACLS training must be present when patients are present. In addition, the training must include “hands on” airway management training and automated external defibrillator (AED) use during ACLS and PALS training and retraining.
Chapter 24 (previously 18) – Radiation Oncology
Treatment Services
D. A change was made to further clarify the standard.
F. The elements of this standard were revised to address current technology.
Chapter 25 (previously 23) – Managed Care
Organization
Chapter 26 (new) – Lithotripsy Services
This chapter was developed to provide standards for renal lithotripsy services when made available by the organization, regardless of whether this is an ASC or free-standing lithotripsy organization.
Chapter 27 (new) – Medical Home
This chapter was developed to provide standards that address Medical Homes. This chapter will be applied only to organizations that choose this chapter in the Application for Survey.
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