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Although the accreditation survey is of necessity evaluative, AAAHC emphasizes the educational and consultative benefits of accreditation. AAAHC uses health care professionals and administrators who are actively involved in ambulatory health care settings to conduct accreditation surveys. These dedicated individuals offer their time to serve as surveyors and use their practical knowledge in the consistent application of the standards.
Each accreditation survey is tailored to the type, size, and range of services offered by the organization seeking accreditation. The length of the on-site visit and the number of surveyors sent by the AAAHC are based on a careful review of the information provided in the Application for Survey and supporting documents submitted by the organization. Questions regarding the scope of a survey should be directed to the AAAHC office before the survey.
Accreditation decisions are made by the AAAHC after careful review of the information gathered during the survey and documented in the survey report, any other applicable supporting documents, and recommendations of surveyors and staff. All documents reflecting the opinions or deliberations of any AAAHC surveyor, staff member, committee member, or its officers or directors constitute peer review materials and will not be disclosed to the organization seeking accreditation or to any third party.
AAAHC expects substantial compliance with the applicable standards. Accreditation is awarded to organizations that demonstrate substantial compliance with the standards and adhere to the AAAHC accreditation policies. Compliance is assessed through at least one of the following means:
1. Documented evidence
2. Answers to detailed questions concerning implementation
3. On-site observations and interviews by surveyors
The overall compliance with the AAAHC standards determines the length of the accreditation term. Organizations receive a copy of the factual findings after the survey as part of the survey process.
Responsibilities of the Requesting Organization
Information provided by an organization seeking AAAHC accreditation or re-accreditation is a critical component of the assessment process. The accuracy and veracity of that information is essential to the integrity of the AAAHC’s accreditation program. Such information may be verbal in nature, may be obtained through direct observation by AAAHC surveyors, or may be derived from documents supplied by the organization. The AAAHC requires that each organization enter into the accreditation relationship and process in good faith.
Failure to participate in good faith during the accreditation process and during any subsequently awarded term of accreditation, including, but not limited to, the submission to AAAHC of falsified, inaccurate, or incomplete documents or information, or failure to pay applicable fees, may be grounds for denial or revocation of an organization’s accreditation status; the basis for terminating an application or an appeal; the basis for ceasing to do business with the organization; or the basis for granting a lesser term of accreditation. When an organization fails to act in good faith, it forfeits its right to appeal or reconsideration of any such action by the AAAHC. In the event that an application or appeal process is terminated, the AAAHC is entitled to retain the application and survey fees or any other applicable fees paid by the organization.
An organization’s duty to provide complete and accurate information continues during the entire accreditation experience. If an organization experiences significant changes after it submits it's Application for Survey, but before an accreditation decision is reached, the organization must notify the AAAHC in writing within five (5) business days of this change. Failure to notify the AAAHC promptly may result in immediate termination of an application for accreditation or immediate revocation of accreditation.
The On-Site Survey Process
The survey of an ambulatory care organization is conducted by surveyors selected by the AAAHC. Surveyors are physicians, dentists, podiatrists, pharmacists, registered nurses, ambulatory health care facility administrators, and other health care professionals who are in active practice and/or have substantial experience in ambulatory health care. Specific survey team members are selected, to the extent possible, on the basis of their knowledge of and experience with the range of services provided by the organization seeking an accreditation survey. In the interest of objectivity, the AAAHC cannot honor requests for specific surveyors.
Organizations are notified in advance to have specific documents and other information available for surveyor review during the on-site visit. This allows surveyors to review and gather information with minimal disruption to the organization’s daily activities. Surveyors may, however, ask to see additional documents or may request additional information during the on-site survey.
For organizations that perform surgeries or procedures, it is necessary for the surveyors to observe a surgery or procedure.
An organization’s failure to provide information requested by the AAAHC or by the surveyors, or an organization’s failure to allow surveyors to observe a surgery or procedure, may be grounds for termination of the survey or accreditation process.
During the on-site survey and as stated in the Notice of Accreditation Survey, the AAAHC provides an opportunity for members of the general public, as well as patients and staff of the organization, to present to AAAHC surveyors pertinent and valid information about the surveyed organization’s provision of health care or its compliance with the AAAHC standards. Alternatively, individuals may present such information in writing to the AAAHC office. All information received from individuals will be considered in the accreditation process.
The opportunity for individuals to present information in person is usually scheduled during the morning of the first survey day and normally does not exceed a total of one hour in length. The time and length of the session should be agreeable to all parties concerned, but final authority for such matters rests with the AAAHC Survey Chairperson. The surveyed organization will provide reasonable accommodations for the session, which is chaired by the AAAHC surveyor.
The session will consist of the orderly presentation of information, verbally or in writing, within the scheduled time. All information received will be considered for pertinence and accuracy, and the findings may be included in the survey report if applicable.
A request to present information during the on-site survey must be received by the AAAHC office at least two weeks before the survey date(s) to allow time to schedule the session. Any such requests received by the organization to be surveyed will be referred to the AAAHC office. The organization to be surveyed is responsible for informing the requesting individual of the date, time, and place for the presentation of information to the surveyor.
At the conclusion of the on-site survey, the surveyors hold a summation conference at which they present their findings to representatives of the organization for discussion and clarification. As the surveyors are “fact finders” for the AAAHC and do not render the final accreditation decision, no information regarding the organization’s compliance with the AAAHC standards or the accreditation decision is provided during this conference. Members of the organization’s governing body, medical staff, and administration are encouraged to take this opportunity to comment on or rebut the findings, as well as express their perceptions of the survey.
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