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Governance Unit: Accreditation

Centralized criteria supports accreditation and certification

Accreditation Committee (AC) aims to ensure objectivity and consistency in the AAAHC accreditation and certification decision-making by centralizing the decision-making criteria and processes and ensuring compliance; to review process and decision policies recommended to and approved by the Board of Directors; to provide oversight of the AC Workgroups assigned to support AC activity.

Reports to Board of Directors

Activities and responsibilities

  • Recommend Work Group members as necessary to aid in its duties. The Work Groups recommend accreditation and certification decisions resulting from review of applications, relevant survey reports, surveyor and staff recommendations, and supporting documentation.
  • Render decisions pertaining to accreditation and certification for all AAAHC surveyed organizations. This includes the application and reconsideration of interim survey decisions.
  • Establish criteria and recommend policies to guide the consistent execution of the decision-making process in order to facilitate the timely release of accreditation and certification decisions.
  • Monitor Work Group performance statistics to ensure consistent, thorough and timely decisions are made.
  • Coordinate with the Complaints Investigation Committee to ensure alignment on policies for interim onsite surveys, Immediate Jeopardy issue management, revocation decisions or renewal denial.
  • Establish an annual Accreditation cluster face-to-face meeting to which all AC Work Group and Complaints Investigation Committee members are invited (at the annual November meeting) to provide policy and procedure updates, share trends, discuss risks and mitigation strategies, and establish priorities for the subsequent year to ensure alignment with Board and budget expectations.
  • Comply with all Governance Unit and AAAHC policies.
Authorities
  • Render accreditation and certification decisions in compliance with AC recommended and Board of Directors approved policies and procedures.
Composition, Expertise or Experience Required
  • Interest in promoting quality in ambulatory care with ability to think beyond a single specialty or ambulatory setting type.
  • Professional experience in an ambulatory health care setting. Technical or clinical expertise in a clinical specialty.
  • Good working knowledge of the AAAHC accreditation and certification standards.
  • Knowledge of other regulatory requirements such as CMS Deemed Status regulations is a positive.
  • Must have a recommendation from a member of the Accreditation Committee.
  • Must be an active surveyor with chairperson privileges for at least three years.
  • Good demonstrated performance based on: Surveyor peer evaluations, client organization evaluations, Survey Report completion, staff concurrence.
Benefits of Membership
  • Gain insight as to how sustained quality and regulatory compliance can be ensured.
  • Occasional opportunity to serve as faculty regarding the accreditation or certification programs.
  • Contribute to the improvement of ambulatory care quality and patient outcomes.

See our Governance Unit Application Process here


Annual Time Commitment Requirements

Activity# Per YearDurationDay/TimeLocation
Face-to-face meetings1-20.5-1.0 daysVariableVariable
Conference calls6-12 *1.0-1.5 hrsEvenings
Hours/year of committee work required outside of meetings/calls12-15Additional travel or time commitmentsNone

 

* AC calls occur on an as needed basis. Conference calls are scheduled when a decision list cannot be ratified via email vote or if a special action is requested of the Committee.


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