SDS Accreditation Update

Changes announced to 2010 standards

There are many accreditation standard changes by the Accreditation Association for Ambulatory Health Care (AAAHC) effective with this month's publication of the 2010 Accreditation Handbook for Ambulatory Health Care.

For the first time since the handbook was published, a new core chapter has been added: "Infection Prevention and Control, and Safety." The chapter includes specific requirements on equipment sterilization, a sharps injury prevention program, and an infection control program that includes guidelines from nationally recognized sources. Sponges, sharps, and instrument counts are now required. Also, "there are very specific requirements on monitoring and documentation of cleaning or disinfection of materials, medical equipment, accessories," says Michon Villanueva, AAAHC assistant director of accreditation services.

All AAAHC/Medicare deemed information, which appears in chapters throughout the handbook, also will be contained in a separate handbook section titled Policies and Procedures for Ambulatory Surgery Centers Seeking AAAHC Accreditation and Medicare Deemed Status. Included is a reference document demonstrating the "crosswalk" between AAAHC standards and Medicare requirements for ambulatory surgery centers (ASCs). "It's helpful to understand what are the requirements, especially for those seeking Medicare certification for the first time," Villanueva says.

The surgery services chapter includes an additional requirement for policies about antisepsis that involve hand hygiene and surgical attire. Staff are no longer allowed to wear their work attire into the facility from outside, Villanueva says. For example, "we don't want them to go out for lunch and come back and go into a sterile area," she says.

In the pharmaceutical standards (Chapter 11), providers who prescribe medications must provide appropriate patient education or tell patients where they can obtain further information, Villanueva says. Also, the facility most maintain a list of look-alike, sound-alike medications and address how to prevent errors with these medications, she says. Also, the facility most have processes to address the maintenance, cleaning, distribution, and use as nebulizer units, IV infusion pumps, and other mechanical device used in the medication delivery process, Villanueva says.

Some of the other revisions to the AAAHC standards include additional requirements for risk management that an active infection control program be implemented (Chapter Five), and new directions for demolition, construction, or renovation of ambulatory organizations (Chapter Eight).

For its part, The Joint Commission has changed some wording and adding some technicality related to the hospital deeming application for Medicare. Some minor changes were made to credentialing and privileging for telemedicine, which are effective July 15, 2010.