Presenter 2018 Accreditation Association for Ambulatory Health Care Inc All rights reserved 2 Joy Himmel PsyD PMHCNSBC LCPC NCC AAAHC Faculty AAAHC Board Member AAAHC Accreditation Committee Member ID: 751606
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Debunking the Myths
Achieving AAAHC Accreditation for Smaller SchoolsSlide2
Presenter
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Joy Himmel
PsyD
, PMHCNS-BC, LCPC, NCC
AAAHC Faculty
AAAHC Board MemberAAAHC Accreditation Committee MemberAAAHC Surveyor since 2009Slide3
Co-Presenter
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Catherine Brocker, NP-C, MSN
Director of the Student Health Center
Marymount University, Arlington, VAAAAHC Accreditation 2018Slide4
Identify the steps required to start the process of getting ready for accreditation
Identify the eight core and applicable adjunct chapters required for accreditation compliance Discuss how smaller schools have been able to achieve accreditation
Today’s Agenda
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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The AAAHC mission
Improve health care quality through accreditation
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Includes: College health, ASCs, OBS centers, immediate/ urgent care, community health, managed care, military health, and dental
Includes over 260 college health center sites, from large universities to small private schools
AAAHC accredits >6,000 facilities
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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High quality evidence-based standards
Surveyors are practicing health care professionals with backgrounds in college health
Focused on care at the patient-provider levelSlide8
Guidance for better patient care through continuous quality improvement
Patient assurance of quality of care
Patient-facing recognition
Staff development
Accreditation process is a true form of peer review
Accreditation benefits
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Has AAAHC accreditation improved your management of care for patients with high health care needs?
AAAHC Institute Oct 2017 survey of accredited organizations
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Perceptions of accredited organizationsSlide10
Primary Care Organizations: Has AAAHC accreditation improved your delivery of preventive care?
AAAHC Institute Oct 2017 survey of accredited organizations
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Perceptions of accredited organizationsSlide11
Gain the support of your administration
Identify resourcesObtain a current AAAHC Handbook to review the applicable StandardsCore Chapters
Relevant Adjunct ChaptersHow do you get started?
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Use the 2018 AAAHC Handbook to conduct a self-assessment
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Chapter 1 – Patient Rights and Responsibilities Slide13
It’s likely you are more ready than you think
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Policies and procedures
Approved by the governing body
Records review
ClinicalPersonnelCredentialsLogbooks and schedules
MaintenanceEquipmentCleaningSlide14
AAAHC Core Chapters
2018
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Core Chapters
Chapter 1: Patient Rights & Responsibilities
Chapter 2: GovernanceSubchapter 2.I: General Requirements Subchapter 2.II: Credentialing & Privileging
Subchapter 2.III: Peer ReviewChapter 3: AdministrationChapter 4: Quality of Care Provided
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Chapter 5: Quality Management & Improvement
Subchapter I: Quality Improvement Program
Subchapter II: Risk Management
Chapter 6: Clinical Records & Health Information
Chapter 7: Infection Prevention & Control & SafetySubchapter I: Infection Prevention & ControlSubchapter II: SafetyChapter 8: Facilities & Environment
Core Chapters
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Chapter 9: Anesthesia Care Services
Chapter 10: Surgical & Related ServicesSubchapter 10.I: General RequirementsChapter 11: Pharmaceutical Services
Some Standards in these chapters are likely to be N/A, depending on the services you provide
Adjunct Chapters most likely to apply
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Chapter 12: Pathology and Medical Laboratory Services
Chapter 13: Diagnostic and Other Imaging ServicesChapter 16: Health Education and Health PromotionChapter 17: Behavioral Health Services
Chapter 18: Teaching & Publication ActivitiesSome Standards in these chapters are likely to be N/A, depending on the services you provide
Adjunct Chapters most likely to apply
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Forms and Worksheets
Sample application for privileges
Credentials filesClinical recordsPersonnel filesQI Flowchart
Step-by-step development of QI studyReview any additional sites
Use the AAAHC Handbook tools
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Typically 5 months from application to decision
Submit the online application
Non-refundable application fee
Supporting documentsKeep your staff prepared and excitedNo need for anxiety!
Work with Scheduling Office to confirm a dateAccreditation process:
How long does it take?
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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300 surveyors nationwideProfessionals actively involved or are experienced in ambulatory health care – specifically, college health
Surveyors receive initial mentored training prior to obtaining surveyor privilegesSurveyors receive continuous intra-cycle trainingSurveyors are reappointed every two yearsSurveyor Training and Education Committee provides oversight
AAAHC surveyors are peers
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Our approach to the survey process
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Discovery vs. inspection
Consultative vs. prescriptive
Collaborative vs. dictatorialSlide23
Typically 1-2 surveyorsArrival at mutually agreed-upon time
Opening orientation conference with key clinical and administrative leadershipBrief tour of the facilityDetailed review of the facilityReview organizational policies, procedures and other documentation to support compliance with the Standards
The on-site survey is an open book test
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Review random selection of clinical records, credentialing, and personnel files
Individual interviews with clinical and administrative staffSummation conference held with key clinical and administrative leadership of the organization to share survey findingsSlide24
Total Enrollment: 3,375
Location: Arlington, VirginiaStudent Health Center Staffing:1 Director/NP, 1 FT NP, 2 RNsPT Wellness Coordinator
Clinic ManagerAdministrative assistantCollaborative Physician & Psychiatric NP (contract workers)Co-located with Counseling Center
Marymount’s Journey
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Gain University Administration Support
Purchase Manual
Attend AAAHC ConferenceDevelop a Team ApproachIdentify Strategic Partnerships
Getting Started
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Timeline
2015
2016
2017
2018
Started role as Director
Transitioned to new EHR system
Organized policies & procedures
Launched annual competencies & trainings
Initiated Patient Satisfaction Survey through ACHA
Assigned chapters to staff: Safety/Infection Control/QI
Completed 1st QI Project
Credentialed all advance practitioners
Launched peer review
Completed 2nd QI project
Submitted Application; Mock Survey
Successful Site Visit!Slide27
Helpful Resources
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Neighboring accredited schoolsElectronic Credentialing ServicePolicy Organization Software
Electronic Health Records SystemsMock SurveyCall or email AAAHC with Questions Slide28
How large is your school?
Among the smaller schools, are any of you accredited?What were your challenges?
How were you able to overcome them?What advice would you give other smaller schools considering accreditation?What are your greatest fears about accreditation?
Let’s Discuss
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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Obtain the AAAHC Handbook; can be ordered online at
www.aaahc.org Consider attending an Achieving Accreditation program - a great way to network with accredited peers; they will help you!
September 14-15, 2018 in Washington DCNovember 30-December 1, 2018 in Las Vegas, NV
Send questions to info@aaahc.org Share what you learn with your colleagues
It’s an important decision!Choosing accreditation
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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We look forward to helping you strengthen your care
© 2018 Accreditation Association for Ambulatory Health Care, Inc. All rights reserved.
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