Posted in: Triangle Times Today

Volume 4 | Issue 1 | January 2025

Message from the CEO

As we step into 2025, I want to take a moment on behalf of the AAAHC Board of Directors, our Surveyors, and the entire AAAHC headquarters team to express our heartfelt gratitude for your continued trust and partnership throughout 2024. It is an honor to support you in your journey of 1095 Strong, quality every day.

From a patient care and practice perspective, 1095 Strong is about being continuously ready. While the onsite survey is important, our mission goes beyond that. Our goal is to ensure quality patient care throughout the entire three-year accreditation term—and well beyond. This means that accredited organizations, including yours, must be “survey-ready” every single day by maintaining high
standards of care when patients walk through your doors.

There is a corollary to this expectation at AAAHC: as an organization, the AAAHC Board holds my team, our Surveyors, and me accountable for providing you with the resources and support to succeed in our shared commitment to delivering safe, high-quality patient care.

This commitment drove our investment in 1095 Engage, our new accreditation management system, and it will continue to guide enhancements in our systems, including Standards development, Surveyor recruitment and training, and other educational resources that add value to your quality improvement efforts. We are focused on building a stronger, more seamless partnership with you—one that integrates smoothly into your daily operations and helps you achieve your goals.

1095 Engage is already making a significant impact, driving engagement, boosting productivity, and generating valuable data that will help shape future decision-making. Thank you for your willingness to engage with this new technology platform. Your patience is appreciated as we refine the Change
Notification process and new system workflows that will allow us to better curate Standards, determine survey scopes, and match Surveyor expertise to your specific needs.

Looking ahead to 2025, we are excited about the new opportunities for education, knowledge sharing, process improvement, and growth. We remain fully committed to providing you with the highest level of service and expertise as you continue to navigate the evolving landscape of patient care delivery.

Your dedication to continuous quality improvement inspires us to be better every day. We look forward to working alongside you in the year ahead and are always here to support you. Please don’t hesitate to reach out if you have any questions or suggestions for how we can further enhance our services.

What you do is important. Thank you for your unwavering commitment to excellence.

With gratitude and best wishes for a successful 2025,

Noel M. Adachi
President & Chief Executive Officer | AAAHC

AAAHC Requires Accurate Room Configuration Information in Application

Facilities participating in the AAAHC Ambulatory Accreditation (AMB) or Medicare Deemed Status (MDS) program and identify as either ambulatory surgery centers (ASCs) or office-based surgery (OBS) must report accurate details about the configuration of operating, procedure, and exam rooms. This data is crucial for AAAHC to properly scope the accreditation survey and to assist with the facility’s compliance with regulatory requirements, including state regulations.

For each room type, facilities must provide the following details:

  • Total number of rooms: This is the physical count of rooms in the facility, regardless of whether they are in use or actively maintained.
  • Number of rooms licensed to operate: These are rooms that meet state licensure requirements.
    In states without specific licensure requirements, the number of licensed rooms should be equal to the total number of rooms in the facility, provided they meet state regulations.
  • Number of rooms actively maintained and in operation: These rooms are maintained and available for use, even if not currently in use.

To clarify, the terms “in the facility” and “licensed to operate” may be used interchangeably in certain contexts, but for AAAHC purposes, they have distinct meanings.

“In the facility” refers to the total count of rooms and “licensed to operate” refers to rooms that meet state regulatory licensure standards.

AAAHC offers the following examples to help illustrate the importance of providing accurate room count information.

Example #1: an ASC might report in their 1095 Engage Application the following operating room (OR) configuration:

  • 10 total operating rooms in the facility
  • 8 licensed to operate based on state requirements
  • 6 actively maintained in working condition

Example #2: the facility reported a combination of operating, exam, and procedure rooms:

Importance for Accreditation
Proper reporting of room types and their status is critical to demonstrate compliance with the 1095 Strong, quality every day philosophy. Any changes to this section of the profile require submitting a Change Notification through 1095 Engage. For information on submitting Change Notifications, click here.

Public Comment is coming!

AAAHC will soon be seeking public comment on proposed Standards revisions to the following AAAHC Programs:

  • Ambulatory Accreditation (AMB)
  • Medicare Deemed Status Accreditation (MDS)
  • Patient Centered Medical Home Certification (PCMH)
  • Health Plans/Health Plans FEHB (HP/HPFEHB)

AAAHC has minimized redundancies and improved clarity of requirements across programs and introduced a few more Guidance & References. A subset of existing Standards was revised to align with the focus on individual patient care. This focus is at the patient level — enabling access to health care resources that meet the individual needs of the patient. The revisions address patient education, data collection, scope of services, personal, cultural and religious beliefs, and preferred communication and reflect AAAHC’s position.

AAAHC believes that all people deserve access to quality health care. The AAAHC 1095 Strong, quality every day philosophy guides the development of programs, standards, education, and other resources to help organizations provide safe, quality health care regardless of their specialty, type of facility or practice, patient population served, geographic location or other factors. Public comment provides valuable feedback that supports AAAHC’s efforts to continue advancing the standard of care.

All interested parties, including AAAHC organizations awarded accreditation or certification, Surveyors,
ambulatory health care associations, medical specialty groups, regulatory agencies, and the public at large, are encouraged to review and provide comments on the proposed revisions.

Monitor your AAAHC email or the aaahc.org website for forthcoming details.

Conferences & Exhibits

  • West Valley MCCD Health Services
    California Student Health Services Conference (CaSHS)
    January 31–February 1, Saratoga, CA
  • Southern College Health Association
    2025 Annual Meeting
    March 10–12, Athens, GA
  • Progressive Surgical Solutions
    5th Annual ASC Nurse Leadership Conference
    April 3–4, Dallas, TX
  • Association of periOperative Registered Nurses (AORN)
    Leadership Summit 2025
    April 5–8, Boston, MA

1095 Learn

2025 Achieving Accreditation
• March 20–21
Renaissance Orlando SeaWorld, Orlando, FL
• September 15–17 Virtual
• December 11–12
Red Rock Casino Resort and Spa, Las Vegas, NV

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