Most common deficiencies for AAAHC Chapter 2 “Governance”, Subchapter I “General Requirements”
The most common deficiencies our surveyors see for Chapter 2-I “Governance: General Requirements” of the AAAHC Accreditation Handbook for Ambulatory Health Care.
In order to avoid deficiencies for Chapter 2-I (Governance), the Governing Body must meet a minimum of once a year and keep documented minutes. Most centers have a board that meets and keeps minutes; however, the minutes must include an annual review of the items below. Minutes lacking this approved list is the most common deficiency surveyors see for Subchapter 2.I:
1. Rights of Patients
2. QI Management & Improvement Program
3. Infection Prevention and Control Program
4. Annual Safety Program
5. Policies and Procedures
6. Scope of Care
7. Job descriptions for officers such as Director, Administrator, and Medical Director
These items are simple to add to the annual board minutes and to also meet Standard G: Annual Review of AAAHC accreditation requirements.
Another often deficient Standard is D that requires: “Within 15 Calendar days of significant organization ownership, operational, or quality of care events, the organization notifies AAAHC of the event in writing.” Some organizations fail to let AAAHC know when:
1. The name of the organization changes
2. Majority ownership changes
3. Re-location of the center or an addition in number of ORs
4. Anesthesia level change from MAC to General
5. Change from single specialty to multi-specialty
6. Change in management company or administrator
For the complete list of required agenda items for Governing Body meetings, stay turned for our next blogs.
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*Sources:
“AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.
HealthCon Consultant survey experience