Most Common Deficiencies For AAAHC Chapter 5-II “Risk Management”

The most common deficiencies our surveyors see for Chapter 5-II “Risk Management” of the AAAHC Accreditation Handbook for Ambulatory Health Care:

  • Some centers still have no policy for a method of managing a situation in which a health care professional becomes incapacitated during a procedure. The policy should describe who will take care of the patient as well as who will administer to the provider. If the incapacitated provider is the only anesthesia personnel in the building, the policy should state who will take over anesthesia. If the incapacitated provider is the only surgeon in the building, the policy should state who will take over to safely manage the patient.

  • Some centers are deficient because they lack a method for communicating concerns and taking action regarding impaired healthcare providers. Just having a Zero Tolerance policy does not meet this standard. The policy should state how staff can communicate suspicion of impairment and to whom, as well as the process for doing so.

  • The standard states: encourages reporting of Near Miss events. During the survey, if staff are asked about Near Misses and the staff doesn’t know what the surveyor is referring to, this is a deficiency. Many centers refer to Near Miss as a Good Catch, which is sufficient to meet the standard.

  • The standard states: communication of reportable events as required by law and regulation. If the center does not know what events, if any, their state requires them to report, this is a deficiency.

  • The standard states: definition of incidents may involve patients, visitors, employees, and medical staff. Many centers only include patients.

  • The standard also states: events involving reactions to drugs and material. Many centers do not include these events as an incident.

  • All adverse incidents and events must be reported to the governing board, with evidence of such reported in the board meeting minutes.

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