Part 3: AAAHC Chapter 2 “Governance”, Subchapter I “General Requirements”
Governing Body Agendas
For accredited organizations, the Agenda for the Governing Body’s annual meetings must include review and approval of the following (see Chapter 2 “Governance” of the AAAHC Accreditation Handbook):
• Patient Rights and Responsibilities
• List of approved procedures and anesthesia types (Scope of Care)
• Policies and Procedures manual
• Any new major contracts
• The Risk Management Program
• The Infection Prevention & Control Program
• The Quality Improvement Program with an evaluation of the program
• The Safety Program
• Financial reports
• Long range plans
• Any legal issues
At every subsequent meeting for the year, the Governing Body agenda should include:
• New or revised policies
• Provider appointments or re-appointments (including allied providers such as CRNA, NP, PA)
• Infection Control report
• Safety report
• Internal benchmarking
• Any external benchmarking
• QI report – any QI studies
• Incident reports or other risk issues
• Peer review
• Marketing or advertising
• Patient satisfaction surveys/grievances
To learn how HealthCon can assist with your accreditation/certification needs, visit www.healthconcorp.com or contact us at kmighion@healthconcorp.com
*Sources:
“AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.
HealthCon Consultant survey experience