Part 2: AAAHC Chapter 2 “Governance”, Subchapter I “General Requirements”

Governing Body Agendas

For newly accredited organizations, the Agenda for the Governing Body’s initial meeting must include review and approval of the following (see Chapter 2 “Governance” of the AAAHC Accreditation Handbook):

• Organizational chart

• Mission statement

• Patient Rights and Responsibilities

• List of approved procedures and anesthesia types (Scope of Care)

• Approval of exempt tissues list

• Appointment and reappointment process

• Approval of providers/surgeons credentialing and privileging

• Approval of anesthesia personnel

• By-laws

• Policies and Procedures manual

• Major contracts

• Job descriptions/roles for Administrator, Director of Nursing, and Medical Director

• Risk Management Program and the appointed Risk Manager

• Infection Control Program and Infection Control Coordinator

• Quality Improvement Program

• Fire and Safety Program and the Safety Officer

• Disaster Preparedness Plan

• Financial management and accountability

• Provision of education to students and postgraduate trainees (if appropriate)

• Marketing and/or advertising

• AAAHC Accreditation Standards

• Long range plans

 

To learn how HealthCon can assist with your accreditation/certification needs, visit www.healthconcorp.com or contact us at kmighion@healthconcorp.com

*Sources:

  1. “AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.

  2. HealthCon Consultant survey experience

Kristine Mighion, MD, MBA