Emergency preparedness standards, others change

AAAHC clarifies number, type of emergency drills

Emergency preparedness becomes a more important part of the accreditation survey, according to revisions made to the Accreditation Association for Ambulatory Health Care’s 2006 standards.

Emergency preparedness is raised to full letter standards in the Environment of Care chapter, and more specific requirements are spelled out, says Stephen Kaufman, RN, senior director of accreditation at the AAAHC. "This change is not a reflection of the hurricane season we just experienced, but is a natural progression of the changes we have been making throughout recent years," he explains.

In fact, the changes related to emergency preparedness had been proposed prior to the hurricane season as a result of feedback from accredited organizations, Kaufman says. "Managers have told us that they want more clarity and more direction as to the type of plans, drills, and training that are required to meet these standards," he adds.

AAAHC requires a minimum of four drills that test the entire emergency preparedness plan — not just fire drills, says Kaufman. "Because Medicare requires an Medicare-certified organization to conduct four fire drills each year, the organizations for which we conduct a combined Medicare certification and AAAHC accreditation survey will need to conduct a minimum of seven drills during the year: four fire and three other types of emergency drills," he explains.

The other drills can be related to medical emergency within the outpatient surgery program, tornadoes or other geographically relevant weather emergencies, power outages, or bomb threats, whatever is appropriate to the individual organization’s location and activities, Kaufman says.

Another requirement that has been changed from a subparagraph to a full letter standard is under the Quality of Care section, says Kaufman. The standard that states "the provision of high-quality health care services is demonstrated by at least the following: appropriate, accurate, and complete clinical record entries" has previously been a subparagraph of another standard, he says. "This requirement is so significant that it has been raised to a full letter standard which means that an organization must meet the requirement more fully in order to meet a surveyor’s expectations for compliance," he explains.

A change to the wording of the Surgical Services chapter won’t affect outpatient surgery program managers, but it will make life easier for office-based practices that perform procedures that require only local and topical anesthetics, says Kaufman. "Primary care offices that sew lacerations with the use of local anesthetics were having to prepare for the survey without knowing how much of the surgical services chapter applied to them," he says. The chapter heading now includes the statement that "some standards may not apply to organizations that only perform minor superficial procedures without anesthesia or under local or topical anesthesia."

While the AAAHC standards don’t specify the use of anesthesiologist, certified nurse anesthetist, or registered nurse to administer sedation or other type of anesthesia, a new standard does require the organization to credential and grant privileges to the individuals administering the anesthesia, says Kaufman.

"We recognize that different states define scope of practice for different types of anesthesia providers, so we expect our accredited organizations to grant these privileges in line with the scope of practice allowed in their area," he says. The intention of the new standard is to emphasize AAAHC’s current focus on the importance of granting credentials and privileges, he explains.


For more information about Accreditation Association for Ambulatory Health Care’s 2006 standards, contact:

  • Stephen Kaufman, RN, Senior Director of Accreditation, Accreditation Association for Ambulatory Health Care, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091. Phone: (847) 853-6060. Fax: (847) 853-9028. E-mail: skaufman@aaahc.org.

At press time, the 2006 standards revisions were scheduled to be posted by Jan. 1. To view the revised standards, go to www.aaahc.org and choose "annual standards revisions" on the left navigational bar, then select "2006 standards revisions."