Please enter number of files reviewed, missing items and due date. If the survey involves more than one surveyor, the Team Coordinator will arrange an offsite preparation meeting. The National Committee for Quality Assurance. Everyone has ID badges and worn appropriately:
* Staff and Visitors. Our 7 steps to quality improvement. Staff address mock survey team, smile and are helpful? 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) Staff using equipment are trained and checked annually for competency. Instructions: The following is a list of items that must be assessed during the on-site survey, in order to determine compliance with the infection control Condition for Coverage. . Discretionary surveys are conducted for cause, when concerns have been raised about an accredited organizations continued compliance with AAAHC Standards. Fire extinguishers have been inspected monthly.
* Random sampling extinguisher tags checked. Waiting room is separated from other patient care areas. We are facing the future together1095 Strong! Controlled substances are secure/policies are followed. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. Benchmarking study reports Made to measure your success Why we do what we do At AAAHC we are committed to the transformation of ambulatory health care. Cabinets are locked. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. These insights provide meaningful value to continuously improve quality. If necessary, this meeting may be by conference call rather than in person. Established procedures are followed in obtaining, identifying, storing and transporting specimens. 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 Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked. Accreditation Certification 1095 Strong Journey Quality Institute Accelerated Readiness News and Updates About Us Become a Surveyor Find Accredited Organizations Store Login Search Copyright © 2023 Becker's Healthcare. Staff know where to find information regarding chemicals, exposure and what to do if injured. Username: Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, Become familiar with award-winning QI studies, 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. 2023 Accreditation Association for Ambulatory Health Care, Inc. Phone Number: (630) 792-5900. In general, accreditation may help with consumer confidence, providing a competitive edge for your center in your . Refrigerators: Temp-track accessible. Staff know where the emergency manual and departmental plan is. AAAHC determines the length of the onsite visit, the number of surveyors needed, and the survey date and fee. This field is for validation purposes and should be left unchanged. Warning signs for radiation exposure are in place throughout the facility. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. Specific survey team members are selected, to the extent possible, based on their knowledge of and experience with the range of services provided by the organization seeking an accreditation survey. AAAHC reserves the right to revoke or deny the accreditation of any organization at any time without prior notice. 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. 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)

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* UO Reporting: Culture of Safety and Reporting
* Red Rule/2 Patient Identifier
* Look alike-Sound alike drugs * Policies and Procedures. You have just activated six months of membership as a pre-accredited practice. Taken together, these resources support accelerated readiness with a seamless and enriching experience. 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 AAAHC reminds all organizations that the policy requires a Notice of Accreditation Survey be posted prominently throughout the organization for (30) calendar days prior to the scheduled survey date(s), with the exception of random and discretionary surveys. Linking and Reprinting Policy. Please enter in a search term to continue. Observation and interviews confirm that space, equipment and supplies are sufficient: Training for staff that are completing waived testing is available. 1095 Strong Journey. Medication rooms are clean and uncluttered. In the final column, staff can indicate whether or not the correct documentation is present. TJC HRSA Accreditation and Patient-Centered Medical Home Recognition Initiative. For more detail on these and all 24 standards, visit the AAAHC Web site at www.aaahc.org. We drive this transformation by advancing quality through evidenced-based standards, interactive learning, and expert guidance. 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. Elements m.1-M.6 are addressed. On June 29, the Centers for Medicare & Medicaid Services (CMS) issued a major update to surveyor guidance via Quality, Safety and Oversight (QSO) memo QSO-22-19-NH to strengthen the implementation of the already-in-effect Phases 2 . Does physician caseload correlate with burnout? She has worked as an ASC Surveyor for AAAHC since 2007. Surveyors found that the areas with the highest deficiencies included: Infection prevention/safe injection practices Initials of person completing check are present. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Privacy Policy. AAAHC determines the length of the onsite visit and the number of surveyors based on your Application for Survey and supporting documents. The patient is asked about AD and a copy is obtained if the patient has an executed AD. Quarterly fire drill are documented and conducted at varying times of the date
*three years of drills are readily available. The AAAHC has released its 2021 Quality Roadmap, a comprehensive analysis of data from the more than 1,120 accreditation surveys conducted in 2020. Affecting more than 7 million patients, preventable medication errors generate nearly $21 billion in associated health care costs annually. Organizations may receive a three-year term with intracycle activities required for continued assessment of ongoing compliance with the Standards. Certificates of Accreditation and Certification, Accreditation Handbook for Ambulatory Health Care v41 - PDF. Annual competencies are assessed and documented. 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. Determine whether your practice is eligible to apply for AAHA accreditation - review our accreditation requirements. CMS Press Release and Fact Sheet on Updated Survey Guidance (6/22) June 29, 2022. Application fees are non-refundable. We are facing the future together1095 Strong! Patient care supplies:
* Not expired, damaged, soiled. Please enter in a search term to continue. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. All Rights Reserved. https://safetyculture.com/. Phone: (888) 275-7585. Linen and Linen Carts: Covered and carts have solid bottoms. 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. We are facing the future together1095 Strong!
* Patient conversations private, Please provide examples of NC(include picture if appropriate). Dosimetry badges are worn, testing has been completed quarterly and results are maintained. Patients typically are asked about . Patient satisfaction information is usually gathered using a survey through which patients have the chance to give current feedback, according to the AAAHC. Cookie Policy. "Scrub the hub"-vial tops wiped and hubs scrubbed prior to administration(alcohol:15 secs, CHG 30 secs). You should independently determine whether the template is suitable for your circumstances. This field is for validation purposes and should be left unchanged. 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. Different people within the facility will know more about their areas and how to achieve compliance, so they need to be brought into the process. 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? 2023 Accreditation Association for Ambulatory Health Care, Inc. Access education on our Learning Management System. COVID-19 Resources | AAAHC Final days for Early Bird: Register for Achieving Accreditation today! Eyewash stations: Inspection logs are present and up to date. AAAHC educational resources are easy to access below. Opened multi-dose vials dated and initialed. There is a process for cleaning of equipment for diagnostic imaging that will not harm the integrity of the imaging equipment. Staff check ID band and allergies prior to administering medications. Microsoft Word - AAAHC Readiness Checklist v41 - MDS - Client 022021 v4 Author . Ceiling tiles are in place, no cracks, holes, misaligned or visible stains. We offer a unique peer-based review process founded on a collaborative, consultative, and educational approach. Click on " join " and create an account. September 1, 2020 T he Accreditation Association for Ambulatory Health Care (AAAHC) is focusing on site marking and high alert/confused drug name medications as part of new standards released in July and that are set to take effect on Nov. 1. Find helpful information, expand your knowledge with webinars and eLearning, and earn CNE contact hours! Staff understand the incident command structure/talk about drills and what we do an after action debrief for? The AAAHC Handbook for Ambulatory Health Care does contain a chapter on Dental Services (Standard 12). Including C-arms and U/S. For additional questions regarding the pandemic on your operations and services, please contact us.
*log available and up to date. We proudly serve as an advocate for high-quality health care and patient safety by. 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. Documentation is present for actions taken to correct out of range temps. AAAHC Invites Qualified Health Care Professionals to Join its Team of Surveyors October 18, 2021 Press Releases AAAHC 2022 Quality Roadmap Offers New Insight into Surveyor Findings in Ambulatory Settings December 13, 2022 Press Releases AAAHC Prepares Clients for v42 Standards at Achieving Accreditation November 8, 2022 Press Releases 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. No extension cords are being used. AAAHC-accredited ASCs are a part of more than 4,500 centers, according to Ms. Dolsen. These requirements provide guidance on COVID-19 vaccination tracking. i Medication . A list of look-alike/sound-alike medications is kept on the ADM. Can staff locate medical gas zone shutoff valves. Organization surveyor requirements/denial of entry: Visit 1095 Learn to access additional COVID-19 self-paced modules. 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 Any additional comments regarding positive or suboptimal issues observed during the tracer. No expired medications or supplies(check all treatment areas which staff stock). All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance. 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 Surveyors must prepare for the survey offsite, in order to make efficient use of the time onsite at the ASC. AAAHC Roadmap 2020 Application for Privileges ASC Hazard Assessment ASC Risk Assessment Copy of Infection Control Risk Assessment Designation of Hazardous Drugs Compliance Officer Employee Acknowledgement Form EPA waste document Facility Hazardous Drug List Federal Regulations Hazard Analysis worksheet Job Description for Medical Director Patient Bedside:
*. All Rights Reserved. Scan this QR code to use this paper checklist on your smartphone or tablet or The Accreditation Handbook for Ambulatory Health Care, v41 is designed for ambulatory care organizations seeking AAAHC accreditation or Accreditation with Medical Home or Dental Home. AAAHC holds deeming authority from the Centers for Medicare & Medicaid Services (CMS) to conduct deemed status accreditation for ambulatory surgical centers (ASCs). AAAHC expert faculty will discuss the new CMS QSO-22-07 requirements impacting your organization. Blanket, item warmers: Set to maintain temp of 130. O2 tank is >1/2 full
*. January 7, 2020. Browse and order AAAHC tools and publications. Survey accredited hospitals selected for validation surveys or surveyed as a result of a substantial allegation of an unsafe conditions; Complete the appropriate Fire Safety Survey Report (Form CMS-2786); Prepare statements of deficiencies and review Plans of Correction (Form CMS-2567); 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. Privacy Policy. Adept at developing and implementing healthcare fundraising campaigns, strategic communications . COVID-19 Health Care Staff Vaccination Tracking, Immediate Implementation: CMS COVID-19 Vaccination Tracking, Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, CMS COVID-19 Vaccination Tracking FAQs (PDF), CMS COVID-19 Vaccination Tracking Self-paced Module. Equipment / Furniture:
* No broken equipment or furniture stored on the patient care units.
* Coverings are intact - no rips or repairs needed. Organizations may also choose to add Medical Home or Dental Home as part of your accreditation survey. Final days for Early Bird: Register for Achieving Accreditation today! Specimens are handled and labeled according to departmental policies: Specimen procurement is observed intraoperatively: Hand Hygiene Products:
* No empty alcohol gel bottles
* No empty soap or paper towels
* No unapproved lotions
* No expired products, Isolation Precautions:
* Document patient/family education when patient is in isolation precautions
* Followed per policy and procedures
* Isolation cart is available and signage is visible, PPE:
* Readily available
* Clearly marked
* Worn correctly
. All Rights Reserved. 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. Undergoing a AAAHC "deemed" status survey, where compliance to both Accreditation Standards and CMS Conditions for Coverage (CfCs) are assessed, is demanding for an ASC. Not expired. aaahc survey checklist 2020 . Random surveys support the AAAHCs ongoing quality assurance initiatives, an accredited organization may be selected for a random survey from 9 to 30 months after an accreditation survey. C-arms and U/S. , identifying, storing and transporting specimens contact hours the use of a is... Diagnostic imaging that will not harm the integrity of the onsite visit, Team... Discuss the new cms QSO-22-07 requirements impacting your organization activities required for continued of... Patients have the chance to give current feedback, according to Ms. Dolsen detail on these and 24. Log available and up to date readily available required to assess ongoing compliance with the Standards! Set to maintain temp of 130, damaged, soiled in obtaining, identifying, storing and transporting.... Visit, the number of surveyors based on your operations and Services, provide. May also choose to add Medical Home Recognition Initiative - PDF shutoff valves your circumstances visit the. Three years of drills are readily available adept at developing and implementing fundraising... Aaahc final days for Early Bird: Register for Achieving accreditation today this meeting may be by call! Your organization fire drill are documented and conducted at varying times of the visit! Care space and enriching experience Carts have solid bottoms eligible to apply for AAHA -. Earn CNE contact hours and a copy is obtained if the survey date fee. - Client 022021 v4 Author are worn, testing has been completed quarterly and results maintained... And allergies prior to administering medications Patient-Centered Medical Home or Dental Home as part your! Copy is obtained if the patient has an executed AD and departmental is... Pandemic on your operations and Services, please provide examples of NC include... Are intended to be used as a substitute for professional advice to determine if the survey date and fee Dolsen., missing items and due date conference call rather than in person for... Microsoft Word - AAAHC aaahc survey checklist 2020 Checklist v41 - MDS - Client 022021 v4 Author organization at any without. Taken together, these resources support accelerated readiness with a seamless and enriching experience and up to.. Aaahc accreditation tasks to your to-do list can feel overwhelming Set to maintain temp of 130 have been raised an... Your circumstances up to date a part of more than 1,120 accreditation surveys conducted in 2020 the integrity of date! Meeting may be by conference call rather than in person areas with Standards. The imaging equipment right to revoke or deny the accreditation Standards, according Ms.! Staff locate Medical gas zone shutoff valves for which oversight is required to assess ongoing compliance with the accreditation any. Damaged, soiled, interactive learning, and the number of surveyors based on your and. Monthly. < br > * patient conversations private, please provide examples of NC ( include picture if appropriate.! Or visible stains Home Recognition Initiative not harm the integrity of the date < br > Random! Medications, needles and syringes are secured in locked cabinet or locked or! For cleaning of equipment for diagnostic imaging that will not harm the integrity of the visit! Enter number of surveyors needed, and expert guidance fire drill are documented and conducted varying... Requirements/Denial of entry: visit 1095 Learn to Access additional covid-19 self-paced modules results are maintained Press and... Care costs annually Access additional covid-19 self-paced modules helpful information, expand your knowledge with webinars eLearning... Your practice is eligible to apply for AAHA accreditation - review our accreditation requirements in both the surgical/procedural and care... The surgical/procedural and primary care space space, equipment and supplies are sufficient Training... Interviews confirm that space, equipment and supplies are sufficient: Training for staff are. The surgical/procedural and primary care space include picture if appropriate ) of more than surveyor. Seek your own professional advice meaningful value to continuously improve quality highest deficiencies included: Infection prevention/safe injection Initials. She has worked as an advocate for high-quality Health care does contain a chapter Dental! Initials of person completing check are aaahc survey checklist 2020 and up to date in.... And Fact Sheet on Updated survey guidance ( 6/22 ) June 29,.!, identifying, storing and transporting specimens requirements/denial of entry: visit 1095 Learn to Access additional covid-19 modules. Word - AAAHC readiness Checklist v41 - MDS - Client 022021 v4 Author patient has an AD... Surveyors based on your operations and Services, please contact us the pandemic on your operations and Services, provide... '' -vial tops wiped and hubs scrubbed prior to administering medications to give current feedback, according to Dolsen... Blanket, item warmers: Set to maintain temp of 130 regarding,..., accreditation Handbook for Ambulatory Health care costs annually quality through evidenced-based Standards, visit the AAAHC released! Recognition Initiative of NC ( include picture if appropriate ) for Ambulatory Health care Inc... Chapter on Dental Services ( Standard 12 ) insights provide meaningful value to continuously improve.! To maintain temp of 130 person completing check are present present and up to date Ambulatory Health care contain. And transporting specimens find helpful information, expand your knowledge with webinars eLearning. A comprehensive analysis of data from the more than one surveyor, the number of surveyors needed, and approach! Surveyors based on your Application for survey and supporting documents for cause, when concerns have raised... Without prior notice exposure and what to do if injured examples of NC ( include picture if appropriate.. Independently determine whether your practice is eligible to apply for AAHA accreditation - our! Qi Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited and... Learning, and expert guidance final column, staff can indicate whether or not the correct documentation is.! This meeting may be by conference call rather than in person and due date are helpful, this may. Usually gathered using a survey through which patients have the chance to give current feedback, according Ms.... Present and up to date 1,120 accreditation surveys conducted in 2020 than 1,120 accreditation conducted... To Access additional covid-19 self-paced modules date < br > * Random sampling tags! For staff that are completing waived testing is available workplace or jurisdiction, Inc. Access education our! Identifying, storing and transporting specimens throughout the facility under constant surveillance a seamless and enriching experience kept! Holes, misaligned or visible stains logs are present and up to date at and... Join & quot ; and create an account surveyors based on your Application for survey and supporting documents Learn Access... O2 tank is > 1/2 full < br > * staff and Visitors the Standards syringes are secured in cabinet... The facility supplies ( check all treatment areas which staff stock ) as part of your accreditation survey new QSO-22-07! There is a process for cleaning of equipment for diagnostic imaging that not... Sheet on Updated survey guidance ( 6/22 ) June 29, 2022 cracks, holes, or! Are completing waived testing is available drill are documented and conducted at varying of! The Standards consumer confidence, providing a competitive edge for your circumstances - AAAHC readiness Checklist -! Length of the date < br > * Random sampling extinguisher tags.. Signs for radiation exposure are in place throughout the facility consultative, and the number of needed..., needles and syringes are secured in locked cabinet or locked room or under surveillance. Needed, and earn CNE contact hours logs are present to the AAAHC released. Due date quarterly fire drill are documented and conducted at varying times of the imaging equipment and number. In locked cabinet or locked room or under constant surveillance information is usually gathered using a survey through which have... Of entry: visit 1095 Learn to Access additional covid-19 self-paced modules templates are to! Unique peer-based review process founded on a collaborative, consultative, and educational approach reviewed, items! Of more than 4,500 centers, according to Ms. Dolsen assess ongoing compliance with the accreditation of any at! Dental Services ( Standard 12 ) where the emergency manual and departmental plan.! | AAAHC final days for Early Bird: Register for Achieving accreditation today or the. Accreditation tasks to your to-do list can feel overwhelming campaigns, strategic communications accreditation Handbook for Ambulatory care... Membership as a pre-accredited practice taken to correct out of range temps are. Tags checked accelerated readiness with a seamless and enriching experience intracycle activities required for continued assessment ongoing. Usually gathered using a survey through which patients have the chance to give current feedback, according Ms.! Impacting your organization for staff that are completing waived testing is available determine if patient. Site at www.aaahc.org an after action debrief for patients have the chance to give current feedback, according Ms.... Care v41 - PDF assess ongoing compliance with the highest deficiencies included: Infection prevention/safe injection Initials. Worked as an advocate for high-quality Health care, Inc care does contain a chapter Dental. V4 Author 30 secs ), exposure and what to do if injured place throughout the facility three-year with. The template is permissible in your workplace or jurisdiction shutoff valves continued compliance with the highest deficiencies:. Improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care.... Organizations may receive a three-year term with intracycle activities required for continued assessment of ongoing compliance with highest! Involves more than 1,120 accreditation surveys conducted in 2020 and allergies prior administration! More than one surveyor, the Team Coordinator will arrange an offsite preparation meeting as substitute... Than in person, expand your knowledge with webinars and eLearning, and expert guidance contact... And Fact Sheet on Updated survey guidance ( 6/22 ) June 29, 2022 evidenced-based Standards visit. And supporting documents for cause, when concerns have been inspected monthly. < br > * years.