SDS Accreditation Update

Are you ready for AAAHC changes?

Organization announces new standards

Facilities accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) have new requirements as of March 1, 2013, including one to document all outcomes related to adverse reactions to drugs and materials.

As part of an organization’s definition of an adverse event, a new element requires that it include all events involving reactions to drugs and materials. The expectation is to include unanticipated or unintended responses to drugs or materials. “This requirement enhances a facility’s risk management program,” says Michon Villanueva, MHA, the director of accreditation services at AAAHC.

Another change is encouragement to report near misses, she says. “I think it actually enhances a facility’s risk management program,” Villanueva says.

As part of the governing body responsibilities, an organization’s representation of accreditation to the public must accurately reflect the accredited entity. The governing body should ensure not only are they ensuring marketing and advertising is not misleading, but they also must ensure the accredited entity is accurately portrayed. “For example, an organization may have multiple locations, but chooses only to accredit a portion of those,” Villanueva says. “Those that are not part of the accredited facilities should not be reflected as accredited.”

A new standard (5.I.B) in the quality improvement (QI) subchapter requires a clear distinction between auditing and monitoring activities and actual QI studies.

In the clinical records and health information chapter, a new responsibility of the person in charge of clinical records is the security of the clinical record. That security includes a method of tracking who accesses the record, to block unauthorized access. There is possibility of multiple accesses from several individuals. The facility needs to have a method of tracking who accesses the record to be sure use is appropriate. A current standard regarding written clinical records policies now includes the need to address accountability for editing, deleting and accessing medical record content. The organization has to define access in terms of who is able to enter or change charts.

There are two new standards in the Infection Control subchapter. The first was an element and has been raised to standard level and now requires the organization to adhere to professionally accepted standards of practice, manufacturer’s recommendations, and state and federal guidelines, including but not limited to the cleaning, disinfection, and sterilization of instruments, equipment, supplies, and implants. The second is a new standard which requires that medical devices for use with multiple patients are cleaned and disinfected between patients, following the manufacturer’s instructions or nationally recognized guidelines, whichever are more stringent.

A new standard in the surgical and related services chapter requires a written policy for the risk assessment and prevention practices relating to deep vein thrombosis, when appropriate.