Posted in: Triangle Times Today

Volume 2 | Issue 11 | Nov/Dec 2023

Launch into v43 Standards and Policy Changes

AAAHC is delighted to announce release of its newest version of our program Standards! Organizations are expected to be in compliance with these requirements and policy changes for AAAHC Accreditation and Certification programs.

As part of its continuous improvement, AAAHC has strengthened its focus on 1095 readiness as reflected in some of the changes to the program policies. Additionally, we have evolved our Standards architecture to leverage a new Accreditation Management System (AMS) that unifies all programs through a consistent format. The v43 Standards are effective with launch of the AMS targeted for April. While there were very few substantive changes to the Standards themselves, we have introduced additional guidance and reference for telehealth and telemedicine that will assist organizations in the application of these concepts to the Standards if they are presently used in their organizations. For organizations participating in the Medicare Deemed Status Accreditation program, the Medicare Conditions for Coverage (CfCs) were separated into standalone Standards so that they are clearly identified. The new v43 Standards updates include:

  • Categories: Standards are organized by Category. Each Category groups similar concepts to facilitate organization compliance, streamline the onsite survey process, and minimize redundancy during the 1095 cycle.
  • Statements of Requirement (SOR) and Universal and Selective Standards: Each Category is composed of multiple Standards or Statements of Requirement. The SOR states the overarching intent of the Standard. Within each Category, there are two types of SORs: Universal and Selective. Universal SORs apply to all organizations seeking or maintaining accreditation. Selective SORs apply based on program selection and the relevant services or specialty information pertaining to the organization as provided in the organization’s Application or living Profile.
  • Application of the Standards/Curation: Based on program selection and organization information provided in the Application or updated through the organization’s Profile, AAAHC creates a set of Standards applicable to each organization that includes Selective and Universal Standards.
  • Standards Levels: Standards are assigned levels to distinguish requirements that have the potential to directly jeopardize the immediate safety of patients, employees, and/or members from administrative or other Standards. This stratification allows for prioritizing the Standards with the highest risk to patient and staff safety.
  • Validation Category: The Validation Category allows for the evaluation of the information the organization has submitted through the Application to ensure accuracy and completeness. The Standards in this category verify information such as services, state requirements and eligibility.
  • Physical Environment Checklist (PEC): The AAAHC Physical Environment Checklist was also updated and reorganized to align with the new Standards architecture, but there are no substantive changes.

The v43 handbooks incorporate several new policies and procedures that leverage a new workflow enabled through the AMS. Changes that will be in effect when the AMS launches include:

  • Application and Survey Fee Payment: The Application fee payment is due before an organization submits any information to AAAHC and grants access to the information in the AMS. Effective January 1, 2024, survey fees will be billed upon survey completion with the invoice due upon receipt and prior to accreditation decision release.
  • Preliminary Report: 24–48 hours following the last day of survey, organizations will have access to a preliminary report that provides the organization with an opportunity to begin drafting and implementing a Plan of Correction (POC). The Preliminary Report is not a final report and is subject to change upon AAAHC review.
  • Plan of Correction: Organizations are required to complete a Plan of Correction (POC) for all deficiencies. For participants in the Medicare Deemed Status program, the requirement has not changed. These organizations are required to electronically submit an acceptable POC for all deficiencies within 10 days of receiving the request. For the Ambulatory Accreditation Program (AMB), for each Level 2 Standard rated as Non-Compliant, the organization will be required to electronically submit an acceptable POC to AAAHC before a final decision is rendered.
  • Annual Attestation: The purpose of the Annual Attestation is to ensure a current and accurate organization Profile and facilitate continuous assessment of compliance with the current version of Standards.

Version 43 also debuts the new 1095 Engage Accreditation Management System that will launch for clients on April 3, 2024. This new accreditation and compliance-management portal provides a single-source operations solution for documentation, management of client Profile information, communication, and workflow. The AMS transforms the accreditation process through automation delivering quality and consistency throughout the 1,095 days of the accreditation cycle. It starts with a more comprehensive application used to curate a set of Standards specific for the facility.

We encourage organizations to reference these new and revised Standards and policy changes as a guiding resource for your accreditation journey and to allow your organization to perform target and continuous assessments of your practices throughout the 1,095 days of your accreditation cycle.

You may learn more about v43 changes in the Q&A article that follows and complimentary AMB and MDS webinars at noon CT on January 9 and January 10, respectively.

Benchmarking Studies impact quality improvement

The AAAHC Institute for Quality Improvement offers Benchmarking Studies to help you conduct effective, data-driven improvement within your organization. Know where you stand relative to your peers. Identify performance goals and interventions for quality improvement by participating in benchmarking studies.

Benchmarking Studies are open to any ambulatory health care center. The annual subscription rate provides access to participation in a maximum of four Benchmarking Studies per year (two per calendar year cycle).

The annual subscription model also allows subscribing organizations to access all study reports, regardless of participation, at the end of the study cycle.

To learn more, click here.

v43 Frequently Asked Questions

What are the Standards Levels referenced in the article?

Standards Levels are denoted at each Statement of Requirement to distinguish requirements that directly impact patient and staff safety and care. The Standards Level is one of several factors considered in determining accreditation decisions. There are three Standards Levels:

  • Level 0: Standards in test mode, or during a grace period for implementation.
  • Level 1: Standards which specify, or apply to, activities or processes which DO NOT involve the provision or conduct of patient care, OR the assurance of patient or employee safety.
  • Level 2: Standards which specify, or apply to, activities or processes which involve the provision or conduct of patient care, OR the assurance of patient or employee safety.

What are Selective Statements of Requirement (SORs)?

Selective SORs apply based on program selection and the relevant services or specialty information pertaining to the organization as provided in the organization’s Application or Profile. For example, an organization that provides laboratory services (Category LRD) and Medication Management (Category MED) as indicated in their Profile, must be in compliance with the respective Selective SORs. For an ASC seeking MDS Accreditation, Category Anesthesia & Surgery (ASG) will apply. Standards are labeled Universal or Selective at each requirement to assist in determining applicability.

Are there still Elements of Compliance within the SOR?

As with the current Standards, some of the SORs will be standalone and contain the elements of compliance within the SOR, and some SORs will have Elements of Compliance (EOCs) and Sub- Elements of Compliance (SEOCs). Elements of Compliance (EOC) and Sub-Elements of Compliance (SEOC), are evaluated as Yes, No, or Not Applicable. All EOCs and SEOCs roll up and reflect the level of compliance at the SOR.

When will the Annual Attestation be required?

Once the Standards are effective, clients will be required to conduct and attest to completion of their annual gap assessment and compliance with the effective AAAHC Standards. Accredited organizations will receive an email reminder prior to their annual anniversary date.

Does the Plan of Correction apply to all programs?

Yes. Organizations are expected to correct deficiencies for all Standards rated less than Fully Compliant. This requirement has always been in place. Version 43 introduces the new requirement for clients in the Ambulatory, Health Plans and Patient-Centered Medical Home programs to submit to AAAHC through the AMS a POC for all Level 2 Standards rated Non-Compliant (NC).

How do I learn more about v43 Standards and policy changes?

AAAHC will host webinars in January that address more detail about changes to the Standards and policies. AAAHC will notify all organizations directly and share information via our website.

How do I learn more about the new Accreditation Management System, and when can I get access to build my Profile?

AAAHC is staggering communication regarding AMS access based on an organization’s anniversary date. An upcoming issue of Triangle Times Today will feature the AMS and provide clarity on access.

Conferences and Exhibits

  • IHI Forum — Institute for Healthcare Improvement
    Dec 10–13

1095 Learn

2024 Achieving Accreditation

Onsite events allow live interaction with faculty and peers and opportunities for discussion and Q&A.
• March 20–22
Renaissance Orlando at SeaWorld, Orlando
• December 11–13
Red Rock Resort, Las Vegas

If you are not able to attend one of our onsite conferences, consider joining us virtually! Virtual events enable attendees to access recordings to create a more customized experience.
• September 16–18

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