Posted in: Triangle Times Today

Volume 3 | Issue 11 | November 2024

Understanding Blackout Dates When Scheduling a Survey

Core to the AAAHC mission and vision is the 1095 Strong, quality every day philosophy. 1095 Strong is a commitment to ongoing education and quality improvement, which demonstrate survey readiness not only on the day of the survey but all 1,095 days of the accreditation or certification term.

1095 Engage features and benefits provide an essential part of an organization’s accreditation/certification journey and continued responsibility. Through the 1095 Engage system, once an organization works through the application process, the final step necessary to proceed to Survey Scheduling is acceptance of the Survey Quote. Following final AAAHC Application approval, the system will send an email notification to the 1095 Engage designated Medical Director (with a copy to the Primary Contact) with Quote Acceptance Confirmation instructions. These instructions will guide the user to the 1095 Engage Quote Acceptance Confirmation screen that contains a detailed Attestation and directions for indicating survey blackout dates.

Once AAAHC receives the completed Quote Acceptance Confirmation, the journey proceeds to Survey Scheduling. For most ambulatory surveys, AAAHC schedules surveys with consideration for the organization’s blackout dates.

Note that the Centers for Medicare and Medicaid Services (CMS) prohibits blackout dates for organizations participating in the Medicare Deemed Status (MDS) program.

AAAHC provides insights on effectively using blackout dates

Known as blackout dates, these are specific days on which an organization is not available. AAAHC will exclude these dates from the scheduling process. Use of blackout dates allows AAAHC to be efficient and optimize scheduling dates for all organizations. For effective use of blackout dates in survey scheduling, please consider the following:

  • Blackout dates are limited to five (5) individual dates (not date ranges).
  • Entering blackout dates is optional.
  • Blackout dates may not be available or offered if the organization submits its Application less than 60 days prior to accreditation end date.
  • Key staff must be available during the survey, though AAAHC does not require that all key staff be physically located in the office or surgery center for the full day. Organization staff key to survey completion include Primary Contact, Medical Director, Quality Improvement (QI) Manager, and Safety, Risk, Infection Prevention & Control (IP&C) Manager.
  • If the survey requires a procedure observation, the AAAHC Surveyor will schedule the observation to occur preferably on the first day or as early within the scope of the survey as possible.
  • Organizations should be survey-ready at all times when open and providing patient services—not only on scheduled survey days.
  • Once AAAHC completes survey scheduling, if an organization requests a new date, a postponement fee may apply. Refer to the Survey Postponement Policies in the Policies and Procedures section of the current program handbook.

AAAHC will not schedule surveys on Sundays or federal holidays. AAAHC will only conduct surveys when an organization is open for business and actively providing patient services based on its 1095 Engage Profile/Application.

AAAHC encourages a continuous state of survey preparedness—an every day readiness approach which allows organizations to minimize disruption, ensures all necessary resources are in place, and enhances the overall success of the survey process while continuously delivering quality patient services. Careful selection of blackout dates further contributes to the efficiency and effectiveness of the AAAHC Survey.

Leveraging Quality Roadmap Data

AAAHC is pleased to announce the release of the 2024 AAAHC Quality Roadmap which provides a thorough analysis of data from 1,615 surveys conducted between January 1, 2023–March 31, 2024, using Standards in the Accreditation Handbook for Ambulatory Health Care, v42 (AMB) and the Accreditation Handbook for Medicare Deemed Status, v42 (MDS). The results indicate that facilities continue to have challenges in emergency preparedness, documentation management, credentialing and privileging, and infection prevention and control.

Given the nationwide labor force struggles over the past few years, the AAAHC Quality Roadmap reflected an increase in quality care and personnel related deficiencies. Many health care organizations continue to face turnover and labor shortages; however, the results from this year’s data indicate an improvement in Standards deficiencies in these areas. While health care organizations are not out of the woods with facing turnover and labor shortages, this is the first time since before the pandemic that AAAHC has observed an improvement in these areas.

Deficiencies associated with pharmaceutical management jumped into the top five deficiency areas. These Standards address pharmaceutical storage, security, recordkeeping, safe dispensing, diversion prevention, error prevention for high-alert medications or confused drug names, drug labeling, and vaccine storage and monitoring.

Quality Improvement (QI) Standards improved by 4.5 percent reflecting progress across all organization types.

Access and get the most value from this report

AAAHC encourages organizations to look more closely at these survey findings and take advantage of the focused portfolio of AAAHC educational programs and quality improvement resources to help comply with our best practice Standards—not just on the day of the survey but every day, throughout the 1,095 days of the accreditation term.

To access the 2024 AAAHC Quality Roadmap, visit the aaahc.org website. Use this tool to facilitate quality improvement by taking the following steps:

  1. Compare these findings to your last onsite survey report and your annual self-assessment.
  2. Understand the most common deficiencies relevant to your setting.
  3. Annually and in preparation for your next AAAHC Survey, review your policies, procedures, and practices to ensure they reflect best practices and compliance to relevant AAAHC Standards.
  4. Leverage AAAHC Toolkits and other resources available from AAAHC and other organizations to improve and assure quality.
  5. Share and discuss the findings with others within your organization to drive understanding and effective decision making on QI studies or other corrective actions that may be necessary.

AAAHC applauds the steps accredited organizations are taking to ensure Standards compliance and patient safety remain at the forefront of their day-to-day operations.

Conferences and Exhibits

  • Institute for Healthcare Improvement (IHI)
    December 8–11, Orlando, FL
  • California Student Health Services Conference (CaSHS)
    January 31 – February 1, Saratoga, CA

1095 Learn

2024 Achieving Accreditation Onsite SOLD OUT!
December 12–13, Las Vegas, NV

To learn more about Achieving Accreditation, visit/AAnews.

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