Most Common Deficiencies For AAAHC Chapter 10-I “Surgical and Related Services: General Requirements”
The most common deficiencies our surveyors see for Chapter 10-I “Surgical and Related Services: General Requirements” of the AAAHC Accreditation Handbook for Ambulatory Health Care:
The Scope of Care, including the list of procedures, must be approved by the governing board annually and documented in the meeting minutes.
Each surgeon and physician must be credentialed and privileged for every procedure they do.
All clinical personnel should have BLS certification, and a copy of current cards must be present at the facility.
There must be a written policy for assessing the risk of DVT for patients.
If pediatric patients are admitted, written policies must define their care.
H&Ps must occur within 30 days of the procedure.
An informed consent form must be signed at the facility on the day of the surgery – even if the patient signed a consent in the physician office when the surgery was scheduled.
Every time providers/personnel remove gloves, they must use appropriate hand hygiene.
Temperature and humidity logs should be completed each morning prior to the first patient. The acceptable range should be included on the log.
There must be an immediate surgical note written by the provider performing the procedure unless the provider completed the final report at the end of the procedure.
There must be evidence that the operating provider reviewed the pathology report for any tissue specimen.
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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