Most Common Deficiencies for AAAHC Chapter 3 “Administration”

The most common deficiencies our surveyors see for Chapter 3 “Administration” of the AAAHC Accreditation Handbook for Ambulatory Health Care:

  • Patient satisfaction must be accessed on an ongoing basis and the results must be reported to the Governing Body. Most organizations have results for patient satisfaction but do not have evidence that their results are being reported to the Governing Board. This should be documented in the board minutes; otherwise, there is no evidence that it is being reported.

  • Negative comments or complaints from patients must be addressed. When the same complaints are reported repeatedly, it appears to surveyors that negative patient feedback is not being addressed.

  • Staff job descriptions and orientations should include: “compliance with an adverse incident reporting system”. This is one of the most common deficiencies.

  • Periodic job evaluations should be in personnel files with current competencies - competencies are often not documented. All staff should have a written periodic appraisal or evaluation.

  • If students are present, written policies must address the Standard requirements.

  • Orientation and training must be within the first 30 days of each staff start date. The following items are most commonly excluded from organizations’ orientation check lists (note these items are not a complete list of required orientation items):

  1. Fire Safety & Disaster Preparedness Plan

  2. Emergency, safety and how to use fire extinguishers

  3. Infection Control Program to include OSHA

  4. Safety Program to include exposure control protocol

  5. Risk Management Program

  6. Training in reporting adverse events

  7. HIPAA/Confidentiality

  • Most organizations conduct new employee orientations, but if the checklist/documentation is not dated, there is no evidence to support they were performed within the first 30 days.

  • Annual training must be documented for all employees – this is often missing, especially for long term staff.

To learn how HealthCon can assist with your accreditation/certification needs, visit www.healthconcorp.com or contact us at kmighion@healthconcorp.com

*Sources:

  1. “AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.

  2. HealthCon Consultant survey experience

Kristine Mighion, MD, MBA