AAC Chapter

Introduction to Access, Assessment & Continuity of Care (AAC)

1. Defining AAC (Why This Matters):

• Key Takeaway: AAC is fundamental to a hospital's core mission. It's not just about admitting patients; it's about ensuring a smooth, safe, and effective patient journey from the moment they seek care until their discharge and beyond. Understanding this broad perspective is crucial.

• Training Application:

  • Scenario-Based Learning: Present trainees with scenarios involving patients with varying levels of need (e.g., emergency, scheduled appointment, referral). Ask them to identify the components of AAC that would be most relevant in each situation.

  • Discussion: Initiate a discussion on the potential consequences of deficiencies in any aspect of AAC (e.g., delayed access leading to deterioration, inadequate assessment resulting in incorrect treatment, poor continuity causing readmissions).

2. Scope of AAC (What It Encompasses):

• Key Takeaway: AAC covers the entire patient experience. It touches on administrative processes (registration), clinical evaluations (assessment), and logistical arrangements (transfer, discharge), and the continuation of care in the community. A "systems thinking" approach is needed.

• Training Application:

  • Process Mapping: Have trainees participate in mapping out the key processes within AAC (e.g., from patient arrival to initial assessment, from referral request to transfer completion). This helps visualize the interconnectedness of the elements.

  • Role-Playing: Conduct role-playing exercises where trainees take on different roles within the AAC system (e.g., admitting clerk, triage nurse, physician, social worker). This will expose trainees to the role of multi-disciplinary staff in AAC.

3. Objectives of AAC (What We Aim to Achieve):

• Key Takeaway: The objectives are about patient-centeredness and optimal outcomes. Efficient access minimizes delays in care. Thorough assessment ensures accurate diagnosis and tailored treatment. Seamless continuity supports long-term health and prevents adverse events.

• Training Application:

  • Objective-Oriented Case Studies: Present case studies where the successful implementation of AAC objectives directly impacts patient outcomes. For example:

    • A patient who received timely triage and intervention in the emergency department, leading to a positive outcome.

    • A patient whose care was seamlessly transitioned from the hospital to a community-based rehabilitation program, preventing readmission.

• • Quality Improvement Exercise: Challenge trainees to identify potential areas for improvement within their own hospital's AAC processes. How can access be made easier, assessments more comprehensive, or continuity more robust?

Additional Training Considerations:

• Interdisciplinary Collaboration: Emphasize that AAC is not the responsibility of a single department or individual. It requires close collaboration between clinical staff, administrative personnel, and other support services.

• Communication Skills: Highlight the importance of clear, empathetic, and culturally sensitive communication with patients and their families.

• Documentation: Stress the need for accurate and timely documentation of all aspects of AAC.

• Regular Review: Encourage ongoing monitoring and evaluation of AAC processes, with a focus on identifying and addressing areas for improvement.

Intent of Access, Assessment & Continuity of Care (AAC)

Overall Guiding Principle: The Intent of AAC section articulates why we have these standards. It focuses on the patient's needs and how the hospital is designed to fulfill those needs.

Key Training Areas (Based on the Listed Intent Statements):

1. Providing Information about the Scope of Hospital Services

   • Key Takeaway: Transparency is key. Patients have a right to know what services your hospital provides and, equally important, doesn't provide. This sets realistic expectations and prevents frustrating situations.

   • Training Application:

     • Mock Patient Inquiry Exercise: Simulate patients calling or visiting the hospital with specific requests (e.g., "Do you have a pediatric cardiology department?"). Train staff to accurately and politely explain the available services.

     • Website and Brochure Review: Evaluate the hospital's website and printed materials to ensure they clearly describe the services offered, hours of operation, and any limitations.

     • Referral Pathway Simulation: Map out referral pathways for patients needing services not available in-house. Include external providers (e.g., mental health services, specialized oncology, long-term care facilities)

2. Admitting Only Those Patients Who Can Be Cared For

   • Key Takeaway: Patient safety and ethical care must be paramount. Admitting patients beyond your capabilities creates a higher risk of adverse events and compromises the quality of care.

   • Training Application:

     • Triage Simulation: Conduct triage simulations involving patients with complex or unusual medical needs. Guide staff to make informed decisions about whether the hospital can adequately manage the patient or if transfer is necessary.

     • Resource Availability Checklist: Develop a resource availability checklist for different patient categories (e.g., "Can we provide ventilation for a pediatric patient?"). This helps to streamline decision making in critical situations.

3. Providing Life-Stabilizing Treatment to Emergency Patients, Then Admit or Transfer

   • Key Takeaway: Ethical obligation to stabilize, regardless of capacity. Emergency care always takes precedence. Immediate stabilization is vital. A clear plan for transfer after stabilization is essential.

   • Training Application:

     • Emergency Simulation Exercises: Conduct realistic emergency simulations (e.g., trauma, cardiac arrest) and observe how staff prioritizes stabilization efforts and considers transfer options.

     • Transfer Protocol Development: Develop or refine transfer protocols to ensure efficient and safe transport of patients to appropriate facilities.

     • Legal and Ethical Considerations: Discuss legal and ethical aspects related to patient transfers.

4. Conducting Appropriate Initial and Periodic Reassessments for All In-Patients

   • Key Takeaway: "Assess, then reassess" is a mantra. Ongoing monitoring and evaluation are fundamental to identifying changes in patient status and adapting care plans accordingly. Initial reassessments identify changes in patient's condition, and periodic reassessments adjust the plan of care

   • Training Application:

     • Assessment Skills Workshop: Conduct workshops to refine staff's assessment skills (vital signs, physical exam, neurological evaluation). Focus on recognizing subtle changes that may indicate a deterioration.

     • Standardized Reassessment Tools: Implement standardized reassessment tools (e.g., Early Warning Scores) and train staff on their proper use.

     • Documentation Training: Train staff on the necessary documents required for initial and periodic reassessment.

5. Providing Laboratory and Imaging Services that Commensurate with the Scope

   • Key Takeaway: Diagnostic support must align with clinical services. This includes having the necessary equipment, qualified personnel, and appropriate testing protocols.

   • Training Application:

     • Lab and Imaging Requisition Review: Review the appropriateness of common lab and imaging requisitions for different patient populations.

     • Resource Matching Exercise: Guide staff to determine the appropriate resources given patient’s situation.

6. Providing Continuous and Multi-Disciplinary Patient Care

   • Key Takeaway: "It takes a village." Complex patient needs often require the expertise of multiple specialists. Collaboration and coordination are key.

   • Training Application:

     • Multi-Disciplinary Team Meeting Simulations: Conduct simulations of multi-disciplinary team meetings where staff from different departments collaborate to develop and implement patient care plans.

7. Having a Well-Defined Transfer and Discharge Protocol

   • Key Takeaway: These transition points are high-risk times for patients. Standardized protocols are vital for ensuring safety and preventing adverse events.

   • Training Application:

     • Transfer Audit: Audit a sample of recent patient transfers to identify any deficiencies in the process.

     • Discharge Planning Skills Training: Provide training on effective discharge planning, including medication reconciliation, patient education, and coordination of follow-up care.

8. Ensuring Continuity of Patient Care is Extended to the Community

   • Key Takeaway: The hospital is not an island. Connecting patients with community resources is essential for supporting their long-term health and well-being.

   • Training Application:

     • Community Resource Fair: Host a community resource fair where staff can learn about available services (e.g., home healthcare, support groups, transportation assistance).

     • Discharge Planning Case Studies: Present case studies demonstrating how successful connections to community resources can improve patient outcomes.

AAC - Summary of Standards

Purpose: This section provides a structured overview of the key standards related to Access, Assessment, and Continuity of Care. It serves as a roadmap for ensuring compliance with NABH accreditation requirements.

How to Use This Section:

• Foundation: It's a starting point. Use it to understand what is expected before diving into the details of each standard.

• Gap Analysis: Use it to identify areas where your hospital may have weaknesses or need improvement.

• Reference: It can be a quick reference for specific areas when working on particular projects.

• Comparison: Use it to understand the changes implemented between the 5th and 6th editions.

Key Content Areas & Training Applications:

1. Format of the Summary Table

• 6th Edition Standard: The specific requirement as outlined in the current (6th) edition of the NABH standards.

• 5th Edition Standard: The corresponding standard in the previous (5th) edition. It is important to notice the changes made between both editions.

• Objective Element: A measureable component of each standard. These are the individual points that an auditor will likely check.

• Objective Element Count (and what this tells you):

  • Pay attention to the number of objective elements. A high count generally indicates a complex standard.

  • When the number of objective elements has changed, there has been a consolidation of Objective elements.

2. Standard-by-Standard Breakdown (with Training Insights):

For each standard listed in the summary, consider the following training approach:

• a. Standard 1: Scope

  • 5th edition: The hospital has defined the scope of its services.

  • 6th Edition: The organisation defines and displays the healthcare services that it provides.

  • Objective Element (Number): 4. The hospital ensures its services are aligned with the community needs and regulatory requirements.

  • Training Focus:

    • Developing and understanding hospital scope of service document.

    • How to present this document and educate the staff.

• b. Standard 2: Registration and Admission

  • 5th Edition: The hospital has a well defined registration and admission process

  • 6th Edition: The organisation has a well-defined registration and admission process.

  • Objective Element (Number): 5. The hospital is using written guidelines for registering and admitting patients.

  • Training Focus:

    • Registration guidelines and patient admission based on patient's requirements.

• c. Standard 3: Transfer or Referral

  • 5th Edition: There is an appropriate mechanism for transfer (in and out) or referral of patients

  • 6th Edition: There is an appropriate mechanism for transfer (in and out) or referral of patients

  • Objective Element (Number): 4. The hospital is using written guidelines for registering and admitting patients.

  • Training Focus:

    • Transfer In and Transfer Out guidelines.

• d. Standard 4: Initial Assessment

  • 5th Edition: Patients cared for by the organization undergo an established initial assessment

  • 6th Edition: Patients cared for by the organisation undergo an established initial assessment.

  • Objective Element (Number): 7. The hospital is using written guidelines for registering and admitting patients.

  • Training Focus:

    • Conducting a comprehensive and accurate assessment of patients based on their initial medical requirements

• e. Standard 5: Reassessment

  • 5th Edition: Patients cared for by the organization undergo a regular reassessment.

  • 6th Edition: Patients cared for by the organisation undergo a regular reassessment

  • Objective Element (Number): 5. The hospital is using written guidelines for registering and admitting patients.

  • Training Focus:

    • The skills of periodic re-evaluation

• f. Standard 6: Laboratory Services

  • 5th Edition: Laboratory services are provided as per the scope of services of the organisation.

  • 6th Edition: Laboratory services are provided as per the scope of services of the organisation.

  • Objective Element (Number): 10.

  • Training Focus:

    • Scope and regulatory norms for the laboratory services provided by the hospital

• g. Standard 7: Laboratory quality assurance and safety

  • 5th Edition: There is an established laboratory quality assurance program.

  • 6th Edition: There is an established laboratory quality assurance and safety programme.

  • Objective Element (Number): 7.

  • Training Focus:

    • Implementation of laboratory quality assurance.

    • Laboratory safety measures.

• h. Standard 8: Imaging Services

  • 5th Edition: Imaging services are provided as per the scope of services of the organisation

  • 6th Edition: Imaging services are provided as per the scope of services of the organisation

  • Objective Element (Number): 9.

  • Training Focus:

    • Infrastructure and scope for the imaging services.

• i. Standard 9: Imaging quality assurance and safety

  • 5th Edition: There is an established quality assurance and safety program for safety services

  • 6th Edition: There is an established quality assurance and safety programme for safety services.

  • Objective Element (Number): 11.

  • Training Focus:

    • Quality and assurance in imaging.

    • Safety measures.

• j. Standard 10: Patient Care

  • 5th Edition: Patient care is continuous and multi-disciplinary

  • 6th Edition: Patient care is continuous and multi-disciplinary.

  • Objective Element (Number): 8.

  • Training Focus:

    • How multidisciplinary approach of care benefits the patients.

• k. Standard 11: Health services

  • 6th Edition: The preventive and promotive and health services are provided in a safe collaborate and consistent manner.

  • Objective Element (Number): 5.

  • Training Focus:

    • Collaborative and health services are provided in a safe and consistence manner

• l. Standard 12: Discharge Process

  • 5th Edition: The organization has an established discharge process.

  • 6th Edition: The organisation has an established discharge process.

  • Objective Element (Number): 7.

  • Training Focus:

    • Established discharge process.

• m. Standard 13: Discharge summary

  • 5th Edition: Organization defines the content of the discharge summary

  • 6th Edition: Organisation defines the content of the discharge summary.

  • Objective Element (Number): 5.

  • Training Focus:

    • How to create a discharge summary.

3. Training Activities:

• Interactive Quiz/Game: Create an interactive quiz or game that tests participants' understanding of the standards and their corresponding objective elements.

• "Spot the Gap" Exercise: Present a hypothetical hospital scenario and ask trainees to identify areas where the hospital may be non-compliant with the AAC standards.

• Mock Audit Preparation: Use the Summary of Standards as a framework for conducting a mock internal audit of the hospital's AAC processes.

• Compliance Documentation Development: Have teams develop documents related to Objective Elements ( Standard Operating Procedures )

Understanding Presentation Colour Coding

Purpose: This section explains the color coding system used throughout this presentation. Understanding the colour coding allows trainees to quickly grasp the relative importance of the objective elements at a glance.

Key Elements

• Colour coding defines the Level of Compliance.

• Colour Scheme: Understand the four main colour to know the different level.

• Icon Scheme: Some objective elements will be have unique icons.

Training Application:

• Make sure all staffs knows the different colour and level it represent.

• Use a pop quiz to access trainees' understanding.

• After the training, distribute a summary on the colour coding.

AAC1: Defining and Displaying Healthcare Services

I. Standard Definition:

• AAC1: The organization defines and displays the healthcare services that it provides.

• Underlying Principle: Proactive transparency is essential for patient trust, informed decision-making, and effective service utilization.

II. Key Changes (6th Edition vs. 5th Edition):

• AAC1: No Change in the Standard definition.

• Impact for Training:

  • While the core definition hasn't changed, emphasis is placed on practical applications of the objective elements.

III. Objective Element Deep Dive (Core Content for Each):

• A. AAC1a: The healthcare services being provided are defined and are in consonance with the needs of the community. (C) [Commitment Level]

  • Key Concepts:

    • "Defined" Healthcare Services: A formally documented list outlining the specific medical, surgical, diagnostic, and therapeutic services offered by the organization. This list should include:

      • Clear descriptions of each service.

      • Any limitations or exclusions.

      • Hours of operation or availability.

• • • "Consonance with Community Needs": Alignment between the healthcare services provided and the documented needs of the community served. This requires:

      • Community Needs Assessment (CNA): Regular and documented evaluations of community health needs based on:

        • Public health data (e.g., disease prevalence, mortality rates).

        • Demographic data (e.g., age, income, ethnicity).

        • Community input (e.g., surveys, focus groups, town halls).

• • • • Service Alignment Plan: A documented plan outlining how the organization's services are designed to address the identified community needs. This may include:

        • Prioritizing services based on community needs.

        • Developing new services to fill gaps in care.

        • Modifying existing services to better meet community needs.

• • Requirements:

    • A written and updated document defining healthcare services.

    • Documented evidence of a recent Community Needs Assessment (CNA).

    • A plan demonstrating how healthcare services align with the needs of the community identified in the CNA.

• B. AAC1b: Each defined clinical service shall have diagnostic and treatment services with suitably qualified personnel who provide out-patient, in-patient day care and emergency cover. (C) [Commitment Level]

  • Key Concepts:

    • Defined Clinical Service Scope: Clearly documented scope of each clinical service, including:

      • Specific procedures and treatments offered.

      • Diagnostic capabilities (e.g., lab tests, imaging).

      • On-call coverage and availability.

• • • Suitably Qualified Personnel: Evidence of personnel competency and qualifications for each service. This includes:

      • Credentialing Documentation: Verified licenses, certifications, and training records for all staff providing clinical services.

      • Competency Assessments: Regular evaluations of staff skills and knowledge, documented through:

        • Skills checklists.

        • Direct observation.

        • Performance data.

        • Continuing education and training plans.

• • • • Defined Scope of Practice: Clear job descriptions outlining the responsibilities and limitations of each role.

• • • Continuity of Care Coverage:

      • Must have access to care from the specific departments as needed.

      • Must have on-call coverage.

      • Must have contingency plan should the hospital not have the ability to cover any one aspect.

• • Requirements:

    • Detailed scope for each service.

    • Personnel records available for review.

    • Demonstrated 24/7 service.

• C. AAC1c: Scope of the clinical services of each department is defined. * (C) [Commitment Level]

  • Key Concepts:

    • Departmental Service Scope: Detailed documentation about the following for each department:

      • The specific clinical services provided.

      • Types of patients served.

      • The hours of operation/on-call schedules

      • Any limitations on scope.

      • Accessible Documentation: Must have copies and/or knowledge on all levels and types of staff.

• • Requirements:

    • Each department has it's own scope documentation

• D. AAC1d: The organization's defined clinical services are prominently displayed. (C) [Commitment Level]

  • Key Concepts:

    • Prominent Display: Services must be publicly accessible and easy to find across:

      • Physical Locations: Signage, posters, brochures in high-traffic areas (e.g., lobbies, waiting rooms).

      • Website: Clear and easily navigable descriptions of all services.

      • Information Kiosks: Interactive displays with service directories and maps.

    • 
      

    • Accessibility: Services must be accessible to all users through:

      • Multilingual Materials: Translation of service information into common languages spoken in the community.

      • Assistive Technologies: Website compatibility with screen readers and other assistive devices.

      • Staff Knowledge: Competent staff able to answer service inquiries clearly and accurately.

• • Requirements:

    • Hospital must have prominent services.

    • Must be clear and concise.

IV. Implementation Notes:

• When defining services, avoid vague or overly broad descriptions (e.g., "general medical care"). Be specific about the types of conditions treated, procedures performed, and populations served.

• Ensure that all staff members (clinical and non-clinical) are familiar with the organization's defined services and can accurately communicate this information to patients and visitors.

• Regularly review and update the defined services list to reflect any changes in the organization's capabilities or the community's needs.

V. Example Resources (Templates & Checklists):

• Sample Service Definition Template: A fillable template for documenting the key aspects of each healthcare service (description, scope, limitations, personnel qualifications, etc.).

• Community Needs Assessment Checklist: A tool for evaluating the comprehensiveness and reliability of the organization's CNA process.

• Signage Assessment Checklist: A tool for evaluating the effectiveness of the organization's signage and wayfinding systems in communicating service information.

AAC2: The Organization has a well-defined registration and admission process

I. Standard Definition:

• AAC2: The organization has a well-defined registration and admission process.

• Underlying Principle: A streamlined, patient-friendly, and efficient registration and admission process creates a positive first impression, reduces patient anxiety, and ensures accurate data capture for effective care delivery.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC2: No change. The Standard definition.

• Impact for Training: Focus to be put on processes and documentation

III. Objective Element Deep Dive:

• A. AAC2a: The organization uses written guidance for registering and admitting patients. (C) [Commitment Level]*

  • Key Concepts:

    • Written Guidance: Comprehensive policies and procedures covering all aspects of registration and admission. This guidance should address:

      • Patient Identification: Protocols for verifying patient identity using multiple identifiers (e.g., name, date of birth, photo ID).

      • Data Collection: Instructions for accurately collecting patient demographic, insurance, and medical history information.

      • Consent Forms: Guidelines for obtaining informed consent for treatment, privacy practices, and other relevant authorizations.

      • Financial Policies: Clear explanation of payment options, insurance coverage verification, and financial assistance programs.

      • Admission Criteria: Defined criteria for admitting patients to different levels of care (e.g., inpatient, outpatient, observation).

      • Handling Special Situations: Protocols for managing patients with communication barriers (e.g., language differences, disabilities), unaccompanied minors, and patients under legal guardianship.

• • • Accessibility and Training:

      • Staff Training Records: Documentation of training sessions to make sure new employees have access.

• • Requirements:

    • Documented registration and admission policies and procedures.

    • Staff training records.

    • Evidence that the written guidance is readily available to staff at all registration and admission points.

• B. AAC2b: A unique identification number is generated at the end of the registration. (CO) [Core Objective]

  • Key Concepts:

    • Unique Patient Identifier (UHID) (Also sometimes referred to as a Medical Record Number - MRN): A distinct alphanumeric code assigned to each patient at the time of registration. This identifier:

      • Prevents Duplication: Eliminates the risk of creating duplicate medical records for the same patient.

      • Facilitates Data Retrieval: Enables quick and accurate access to patient information across all departments and systems.

      • Supports Continuity of Care: Ensures that all patient encounters, regardless of location or provider, are linked to a single record.

• • • Generation and Management:

      • Automated System: Must be automatically generated by the organization.

      • Data Integrity: Regular audits must be performed.

• • Requirements:

    • A functional and validated UHID generation system.

    • Policies for UHID usage.

• C. AAC2c: Patients are accepted only if the organization can provide the required service. (C) [Commitment Level]

  • Key Concepts:

    • Service Capability Verification: A process for ensuring that the organization has the necessary resources, personnel, and equipment to meet the patient's specific healthcare needs before admission. This includes:

      • Medical Assessment: Review of the patient's medical condition and required services by a qualified healthcare professional.

      • Resource Availability Check: Verification that the necessary staff, equipment, beds, and support services are available.

      • Capacity Management: Protocols for managing patient flow and capacity to avoid overcrowding or resource shortages.

• • • Documentation and Communication:

• • Requirements:

    • A documented process for service capability verification.

    • Protocols for coordinating with on-call personnel and hospital units.

    • A documented process should the organization be unable to provide patient care.

• D. AAC2d: The written guidance also addresses managing patients during non-availability of beds. (C) [Commitment Level]*

  • Key Concepts:

    • Bed Management Protocols: Strategies for managing patients when beds are unavailable.

    • The requirements include:

      • Temporary Holding Areas: Designated spaces for patients to wait safely and comfortably until a bed becomes available.

      • Triage and Prioritization: Criteria for prioritizing patients based on their medical urgency.

      • Transfer Agreements: Formal agreements with other hospitals or facilities for transferring patients when appropriate.

• • • Communication and Transparency:

• • Requirements:

    • Documented bed management policies and procedures.

    • Protocols for informing patients.

    • Transfer agreements.

• E. AAC2e: Access to the healthcare services in the organization is prioritized according to the clinical needs of the patient. (A) [Achievement Level]*

  • Key Concepts:

    • Clinical Prioritization Protocols:

      • Written protocols for prioritizing access to healthcare services (e.g., triage systems).

      • Defined criteria for determining the level of urgency.

      • Staff Training

• • Requirements:

    • Formal policies and procedures for healthcare services

    • Formal training for staff to make sure standards are met

    • The criteria for determining the level of urgency.

IV. Implementation Notes:

• It is essential that registration and admission staff receive thorough training on all applicable policies and procedures. Regular refresher training should be provided to ensure ongoing competency.

• The registration and admission process should be regularly evaluated to identify areas for improvement. Patient feedback and staff input should be actively sought and used to inform process changes.

V. Example Resources (Templates & Checklists):

• Sample Patient Registration Form

• Consent Form Templates

• Registration Process Checklist

• Patient Satisfaction Survey

AAC3: There is an appropriate mechanism for transfer (in and out) or referral of patients

I. Standard Definition:

• AAC3: There is an appropriate mechanism for transfer (in and out) or referral of patients.

• Underlying Principle: Patient safety, continuity of care, and ethical responsibility dictate that organizations have systems in place to facilitate timely and safe transfer or referral when a patient's needs exceed the organization's capabilities or when the patient requires specialized services elsewhere.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC3: No change. The Standard definition.

III. Objective Element Deep Dive:

• A. AAC3a: Transfer-in of patients to the organization is done appropriately. (C) [Commitment Level]*

  • Key Concepts:

    • Transfer-In Protocols: A documented process for accepting patients transferred from other facilities, ensuring patient safety and continuity of care.

      • Communication Procedures: Clear communication channels and protocols between the transferring and receiving facilities, including:

        • Contact information for designated transfer coordinators.

        • Timely exchange of patient medical information (e.g., records, test results, medication lists).

• • • • Acceptance Criteria: Defined criteria for accepting patients based on the organization's capabilities and resources.

      • Transportation Arrangements: A plan for coordinating safe and appropriate patient transportation (e.g., ambulance, air transport).

• • • Triage and Assessment:

      • Rapid Triage System: A system for quickly assessing the patient's medical condition and prioritizing their care upon arrival.

      • Initial Assessment: A standardized process for conducting a comprehensive initial assessment of the patient's medical needs.

• • Requirements:

    • Transfer-in policy and procedure.

    • Communication protocols for transferring facilities.

    • Criteria for accepting and denying transfers

    • A rapid triage system.

    • A standardized assessment of medical needs

• B. AAC3b: Transfer-out/referral of patients to another facility is done in appropriately. (C) [Commitment Level]*

  • Key Concepts:

    • Transfer-Out/Referral Protocols: A documented process for transferring or referring patients to other facilities when their needs cannot be met within the organization. This includes:

      • Assessment and Justification: Documentation of the medical necessity for transfer or referral, based on objective clinical criteria.

      • Facility Selection: A process for identifying appropriate receiving facilities with the necessary expertise, resources, and capacity to meet the patient's needs.

      • Patient/Family Consent: Obtaining informed consent from the patient or their legal representative for the transfer or referral.

      • Communication with Receiving Facility:

      • Medical Record Transfer: Protocols for transferring patient medical records to the receiving facility in a timely and secure manner.

      • Transportation Arrangements: Coordination of safe and appropriate patient transportation (e.g., ambulance, air transport) to the receiving facility.

• • • Communication and Safety:

• • Requirements:

    • Written transfer-out and referral policies and procedures.

    • Assessment and justification standards

    • Patient and/or family consent.

    • Medical record transfer.

    • Transportation arrangments

• C. AAC3c: During transfer or referral, accompanying staff are appropriate to the clinical condition of the patient. (C) [Commitment Level]

  • Key Concepts:

    • Staffing Based on Acuity:

      • Defined criteria for determining the appropriate level of medical supervision and support required during transfer or referral, based on the patient's medical condition and risk factors.

      • Assignment of qualified staff members (e.g., physicians, nurses, paramedics) to accompany the patient, providing necessary monitoring, treatment, and interventions during transport.

• • • Qualifications

• • Requirements:

    • Accompanying personal are qualified to perform treatment

• D. AAC3d: The organization gives a summary of patient's condition and the treatment given. (C) [Commitment Level]

  • Key Concepts:

    • Medical Summary must include:

      • Complete medical summary, including:

        • Demographic information.

        • Reason for medical care.

        • Initial assessment summary.

        • Allergies and important medical considerations.

• • • Medication List

      • Administration: Medication details (doses, routes, frequencies, dates administered)

• • • Testing and Results:

      • List any/all performed to diagnose the patient

• • Requirements:

    • Medical Summary, including:

      • Demographic information.

      • Reason for medical care.

      • Initial assessment summary.

      • Allergies and important medical considerations.

• • • Medication and Test Lists

IV. Implementation Notes:

• Transfer and referral agreements with other facilities should be reviewed and updated regularly to ensure that they align with the organization's capabilities and the community's needs.

• Staff training should emphasize the importance of clear and timely communication with patients, families, and receiving facilities throughout the transfer or referral process.

V. Example Resources (Templates & Checklists):

• Sample Transfer Agreement Template

• Transfer/Referral Checklist

• Patient Transfer Consent Form

• Medical Record Transfer Form

• Communication Log Template

AAC4: Patients cared for by the organization undergo an established initial assessment

I. Standard Definition:

• AAC4: Patients cared for by the organization undergo an established initial assessment.

• Underlying Principle: A comprehensive and standardized initial assessment is crucial for identifying patient needs, developing effective care plans, and ensuring appropriate resource allocation. This assessment provides the foundation for all subsequent care decisions.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC4: No Change in the Standard definition.

• Impact for Training: Reinforce a standard framework.

III. Objective Element Deep Dive:

• *A. AAC4a: The initial assessment of the out-patients, day-care, in-patients and emergency patients is done in a standardized manner . (CO) [Core Objective]

  • Key Concepts:

    • Standardized Assessment Tools: Use of structured forms, checklists, or electronic templates to ensure that all essential information is gathered consistently for each patient.

    • Required Elements: Key components of the initial assessment should include, as relevant to the patient's condition:

      • Chief Complaint: Patient's primary reason for seeking care.

      • Medical History: Detailed information about past illnesses, surgeries, medications, allergies, and immunizations.

      • Family History: Relevant family medical history.

      • Social History: Information about the patient's lifestyle, habits (e.g., smoking, alcohol use), occupation, and social support system.

      • Physical Examination: Comprehensive evaluation of the patient's physical condition, including vital signs, general appearance, and system-specific examinations.

      • Mental Status Examination: Assessment of the patient's cognitive and emotional state.

      • Functional Assessment: Evaluation of the patient's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

• • • Emergency vs. Non-Emergency

      • Emergency situations must have an abridged form, but should be completed as soon as possible after stabilization.

• • Requirements:

    • Documented standardized assessment tools.

    • Required elements for assessment are to be included.

• B. AAC4b: The initial assessment is performed by qualified personnel. (C) [Commitment Level]*

  • Key Concepts:

    • Defined Roles and Responsibilities: Clear delineation of the roles and responsibilities of different healthcare professionals in conducting the initial assessment. This may include:

      • Physicians: Performing a comprehensive medical evaluation, including history, physical examination, and diagnostic test ordering.

      • Nurses: Collecting vital signs, obtaining patient history, and performing a nursing assessment.

      • All Healthcare Providers: Communicating information, and treating with care.

    • Competency Verification:

      • Training Documentation: Records showing providers are qualified to perform the treatment and collect necessary information.

  • Requirements:

    • Personnel are trained to take patients information, and perform physical exams.

• C. AAC4c: The initial assessment is performed within a time-frame based on needs of the patient. (C) [Commitment Level]*

  • Key Concepts:

    • Prioritized and Timely Assessments:

      • Emergency patients = Immediate assessment.

      • Inpatients = 24-hour time frame.

    • Requirements:

      • Appropriate triage and prioritization.

• D. AAC4d: Initial assessment of day-care and in-patients includes nursing assessment, which is done at the time of admission and documented. (C) [Commitment Level]

  • Key Concepts:

    • Day-Care Documentation: Shortened.

    • In-Patients documentation: Fully documented.

  • Requirements:

    • Policies for nurses

• E. AAC4e: The initial assessment for in-patients results in a documented care plan. (CO) [Core Objective]

  • Key Concepts:

    • Collaborative Plan: Should consider the results of the interdisciplinary team, including:

      • Patient strengths and weaknesses.

      • Patient goals.

      • Objective, measurable activities.

      • Readjusting timeline.

  • Requirements:

    • The care plan will be fully documented and accessible to the care team.

• F. AAC4f: The care plan is countersigned by the clinician in-charge of the patient within 24 hours. (A) [Achievement Level]

  • Key Concepts:

    • Review Requirements: Reviewer must determine is the care plan:

      • Appropriate?

      • Safe?

      • Within Scope?

  • Requirements:

    • Requires the clinician to approve all aspects.

• G. AAC4g: The care plan includes the identification of special needs regarding care following discharge. (E) [Excellence Level]

  • Key Concepts:

    • Discharge Planning:

      • Medication, transportation, support.

    • High-Risk patients

  • Requirements:

    • Must have a follow up plan for these patients.

IV. Implementation Notes:

• Training should emphasize not only the completion of the assessment tools but also the importance of critical thinking and clinical judgment in interpreting the assessment findings.

• The initial assessment process should be integrated with other aspects of patient care, such as care planning, medication reconciliation, and patient education.

V. Example Resources (Templates & Checklists):

• Sample Initial Assessment Forms

• Nursing Assessment Checklist

• Care Plan Template

• Functional Assessment Tool

• Mental Status Examination Guide

AAC5: Patients cared for by the organization undergo a regular reassessment 

I. Standard Definition:

• AAC5: Patients cared for by the organization undergo a regular reassessment.

• Underlying Principle: Regular reassessment ensures that patient care remains appropriate and responsive to changing needs throughout their stay. It promotes proactive management of complications, facilitates timely adjustments to care plans, and contributes to optimal patient outcomes.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC5: Standard Definition stays unchanged. However, it’s important to look at the objective elements to understand changes and how the standards must be changed.

III. Objective Element Deep Dive:

• A. AAC5a: Patients are reassessed at appropriate intervals to determine their response to treatment and to plan further treatment or discharge. (CO) [Core Objective]

  • Key Concepts:

    • Regular Reassessment: Ongoing assessment of patient's condition by doctor or someone from the treatment team.

    • Elements to consider in the reassessment should include

    • Medical Parameters

      • "Based on Patient's condition": The reassessment is based off the patient's current situation and any current or new care requirements.

      • "Documented": the data in the "reassessment" should be documented.

• • Requirements:

    • Periodic medical re-evaluations.

    • Any necessary re-evaluations.

    • Documented reassessments.

• B. AAC5b: Out-patients are informed of their next follow-up, where appropriate. (C) [Commitment Level]

  • Key Concepts:

    • Follow-Up Communication

      • "Informed Date": A plan for telling the patients of any follow up treatments or any follow ups that may be necessary in an agreed method.

      • "In-Record": Details of date, time and the reason for the follow up is recorded for internal communication.

• • Requirements:

    • There is documented follow up communication methods for each patient.

• C. AAC5c: For in-patients during reassessment, the care plan is monitored and modified, where found necessary. (C) [Commitment Level]

  • Key Concepts:

    • Adjustable Care plans based on reassessment.

      • "Dynamic": Care plan should be reviewed.

      • "Improved": If the patients symptoms improve adjustments can be made to the care plan.

• • Requirements:

    • Care plans are adjustable.

• D. AAC5d: Staff involved in direct clinical care document reassessments. (C) [Commitment Level]

  • Key Concepts:

    • Documentation of care plan to include:

      • "Medical Professionals": Should be recorded by a professional medical provider.

      • "What to Include": Include measurable parameters, and should avoid "patient seems better."

• • Requirements:

    • Document the measurable parameters by medical professional in the case sheet.

• E. AAC5e: The organization lays down guidelines and implements processes to identify early warning signs of change or deterioration in clinical conditions for initiating prompt intervention. (C) [Commitment Level]*

  • Key Concepts:

    • Early Warning Sign Tools

      • "Age Group": Specific assessment for all age groups.

      • "Medical Professionals": The person using and acting on the findings is a medical professional.

      • "Training": All staff members must be fully trained.

• • Requirements:

    • Staff has early warning assessment and tools

IV. Implementation Notes:

• When setting reassessment intervals, consider the patient's diagnosis, acuity level, treatment plan, and any potential risk factors.

• Staff training should emphasize the importance of actively listening to patient concerns and incorporating their perspectives into the reassessment process.

V. Example Resources (Templates & Checklists):

• Sample Reassessment Schedule

• Reassessment Checklist for Inpatients

• Communication Log Template

• Early Warning Score Tool

• Patient Feedback Form

AAC6: Laboratory services are provided as per the scope of services of the organization

I. Standard Definition:

• AAC6: Laboratory services are provided as per the scope of services of the organization.

• Underlying Principle: Ensuring that the laboratory services available are appropriate and commensurate with the hospital's overall scope of medical services is critical for accurate diagnoses, effective treatment planning, and ultimately, optimal patient outcomes.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC6: Standard Definition stays unchanged. However, it’s important to look at the objective elements to understand changes and how the standards must be changed.

III. Objective Element Deep Dive:

• A. AAC6a: Scope of the laboratory services is commensurate to the services provided by the organization. (C) [Commitment Level]

  • Key Concepts:

    • Alignment with Scope:

      • "Internal Resources": The organization has adequate resources to perform any routine and medically critical testing.

      • "Emergency Services": The organization has 24/7 access to needed testing, as well as staff competent enough to conduct the services.

• • • Appropriate Testing:

      • "Scope Alignment": Testing performed aligns with care for the patient.

      • "Properly Trained": The staff are well trained to perform testing.

      • "Safe": The safety of the testing is assured.

• • Requirements:

    • 24/7 coverage

    • In house and out-sourced list to help with coverage.

    • Ensure the laboratory is appropriate for the patients it will be used on.

• B. AAC6b: The infrastructure (physical and equipment) is adequate to provide the defined scope of services. (C) [Commitment Level]

  • Key Concepts:

    • Appropriate Workspace

      • "Sufficient Space": To safely and comfortably provide care, and provide a safe and comfortable environment for all patients.

      • "Sufficient Equipment": Ensure appropriate number and access to necessary equipment.

      • "Ergonomic": Ensure work area is designed ergonomically to reduce staff injury or strain.

    • Documentation.

      • "Equipment Maintenance": Ensure all testing and patient care equipment is working properly.

    • Inventory.

      • "Sufficient Resources": All resources to perform the testing and equipment required is available.

  • Requirements:

    • All required resources.

    • A documented process to review and monitor the resources.

    • Properly trained staff.

• C. AAC6c: Human resource is adequate to provide the defined scope of services. (C) [Commitment Level]

  • Key Concepts:

    • Staff Adequacy:

      • Staff are commensurate to the workload that must be completed.

      • Schedules for staffing to ensure the right amount.

  • Requirements:

    • A method to assess workload that has been recorded

• D. AAC6d: Qualified and trained personnel perform and supervise the investigations and report the results. (C) [Commitment Level]

  • Key Concepts:

    • Qualified Personnel:

      • "Qualified Personnel": All individuals perform functions they are qualified to perform by their job description, and with the right amount of training.

      • "All regulations are followed."

  • Requirements:

    • Licenses, Training, and competence.

• E. AAC6e: Requisition for tests, collection, identification, handling, safe transportation, processing and disposal of a specimen is performed according to written guidance. (C) [Commitment Level]*

  • Key Concepts:

    • Collection, Process, and Storage:

      • "Appropriate Collection:" Following correct procedures and using correct equipment.

      • "Documented Guidance": Documentation of appropriate handling and transportation of specimens.

  • Requirements:

    • Detailed Policies and procedures on handling and storage practices.

    • Follow the recommended procedures.

• F. AAC6f: Laboratory results are available within a defined time frame. (C) [Commitment Level]*

  • Key Concepts:

    • Turn Around Time (TAT) standards.

    • Documentation of the following points.

  • Requirements:

    • The standards.

    • Actual times to compare the current with the requirements.

• G. AAC6g: Critical results are intimated to the personnel concerned at the earliest. (C) [Commitment Level]*

  • Key Concepts:

    • What to Include:

      • “Notification to Medical Staff"

      • "Reporting Methods and Documentation"

  • Requirements:

    • Documentation of what the laboratory's actions will be.

• H. AAC6h: Results are reported in a standardised manner. (C) [Commitment Level]

  • Key Concepts:

    • Standard Reporting System:

      • Templates and forms for lab use to follow.

      • Elements such as: name, date, contact info, results, signature.

  • Requirements:

    • A policy of the required elements.

• I. AAC6i: There is a mechanism to address recall/amendment of reports whenever applicable. (A) [Achievement Level]*

  • Key Concepts:

    • Policy Creation:

      • "Corrected Reports": A policy stating what steps must be taken when there has been an error that must be addressed.

  • Requirements:

    • Follow the "Corrected reports"

• J. AAC6j: Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system. (C) [Commitment Level]*

  • Key Concepts:

    • Quality Testing:

      • “Vendor Qualification”

  • Requirements:

    • Vendor has met or exceeded all minimum standards of the organization.

IV. Implementation Notes:

• Regularly review and update the list of laboratory services to ensure that it reflects the changing needs of the patient population and the advancements in medical technology.

• Involve laboratory staff in the development of policies and procedures to ensure that their expertise and perspectives are considered.

V. Example Resources (Templates & Checklists):

• Laboratory Service Scope Document

• Competency Assessment Tool for Lab Personnel

• Specimen Collection and Handling Guideline

• Critical Result Notification Policy

• Quality Control Checklist

• Vendor Qualification Checklist

AAC7: There is an established laboratory quality assurance and safety programme 

I. Standard Definition:

• AAC7: There is an established laboratory quality assurance and safety programme.

• Underlying Principle: A robust laboratory quality assurance and safety program is paramount for ensuring accurate and reliable test results, protecting the health and safety of laboratory personnel, and minimizing the risk of errors or adverse events.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC 7 and AAC 8 merged.

III. Objective Element Deep Dive:

• A. AAC7a: The laboratory quality assurance programme is implemented. (C) [Commitment Level]*

  • Key Concepts:

    • Comprehensive QA Program: Implementation of a formal, documented quality assurance program that covers all phases of the laboratory testing process:

      • Pre-analytic Phase: Procedures for test ordering, specimen collection, handling, transportation, and preparation.

      • Analytic Phase: Controls for instrument calibration, reagent storage, internal quality control, and proficiency testing.

      • Post-analytic Phase: Processes for result reporting, interpretation, and documentation.

  • Requirements:

    • A fully documented and implemented QA system.

• B. AAC7b: The programme ensures the quality of test results through internal quality control. (C) [Commitment Level]*

  • Key Concepts:

    • Internal Controls, including

      • "Documented" Should be documented

      • "Monitor Controls" Should monitor controls to help verify instrument

  • Requirements:

    • Verify instrument and reagents.

• C. AAC7c: Laboratory participates in proficiency testing/external quality assurance scheme. (C) [Commitment Level]

  • Key Concepts:

    • Proficiency testing (PT)/External Quality Assessment (EQA):

      • Regular review and training

      • Use for performance review.

  • Requirements:

    • Has review training.

• D. AAC7d: The programme addresses the clinico-pathological meeting(s). (C) [Commitment Level]

  • Key Concepts:

    • Routine Meeting

      • "Schedule Regular Meeting" All schedule to assess patient care.

  • Requirements:

    • Record of meeting

    • Members of all levels can participate

• E. AAC7e: The laboratory safety programme is implemented. (C) [Commitment Level]*

  • Key Concepts:

    • Safety Programme includes the following safety requirements:

      • "PPE use”: What is required to protect patients.

  • Requirements:

    • Documentation of what the safety guidelines are and why.

• F. AAC7f: Laboratory personnel are appropriately trained in safe practices. (C) [Commitment Level]

  • Key Concepts:

    • Appropriate Training:

      • Staff should be trained in what is required for the position.

      • Documentation required

  • Requirements:

    • What the policy must have.

• G. AAC7g: Laboratory personnel are provided with appropriate safety measures. (C) [Commitment Level]

  • Key Concepts:

    • Safety Measures in Place:

      • "Readily Accessible": For patient and for medical personnel.

  • Requirements:

    • What the materials must be available.

IV. Implementation Notes:

• The quality assurance program should be risk-based, focusing on identifying and mitigating potential sources of error throughout the laboratory testing process.

• Regular audits and inspections should be conducted to ensure that the quality assurance and safety program is being effectively implemented and that all staff members are adhering to the established policies and procedures.

V. Example Resources (Templates & Checklists):

• Laboratory Quality Assurance Manual

• Quality Control Log

• Proficiency Testing Results Summary

• Safety Inspection Checklist

• Incident Reporting Form

AAC8: Imaging services are provided as per the scope of services of the organization 

I. Standard Definition:

• AAC8: Imaging services are provided as per the scope of services of the organization.

• Underlying Principle: Ensuring that the imaging services available are appropriate and commensurate with the hospital's overall scope of medical services is crucial for accurate diagnoses, effective treatment planning, and ultimately, optimal patient outcomes. This involves aligning services with community needs, maintaining qualified staff, and adhering to safety regulations.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC8 was (AAC 9 in 5th edition) NO CHANGE

III. Objective Element Deep Dive:

• A. AAC8a: Imaging services comply with legal and other requirements. (CO) [Core Objective]

  • Key Concepts:

    • Documented Compliance:

      • "All legal Documents" must have a way of maintaining all documents, and keeping them organized.

      • "Follow government regulations" Must follow the pre-conception rules, must inform and receive consent from the patient.

    • Radiation Safety Documentation

  • Requirements:

    • All required documents to provide imaging in one location.

    • That is easily accessible, if needed.

• B. AAC8b: Scope of the imaging services is commensurate to the services provided by the organization. (C) [Commitment Level]

  • Key Concepts:

    • Emergency Services:

      • "Commensurate with other services": To maintain consistency between diagnostic and therapeutic equipment.

      • "24/7 or on call services": Available for the medical team in case there needs to be after hours treatment.

  • Requirements:

    • Coverage of diagnostic and therapeutic services.

    • List of when the equipment is available or people on call if service is unable to be performed.

• C. AAC8c: The infrastructure (physical and equipment) and human resources are adequate to provide for its defined scope of services. (C) [Commitment Level]

  • Key Concepts:

    • Workspace appropriate for services.

    • Sufficient space for staff to complete the required tasks.

    • Proper staffing.

  • Requirements:

    • Ensure adequate space for staff, proper amount of equipment and documentation of the location where information can be obtained.

• D. AAC8d: Qualified and trained personnel perform supervise and interpret the investigations. (C) [Commitment Level]

  • Key Concepts:

    • Required Expertise and documentation

      • "Qualified": They have been documented as appropriate to operate.

  • Requirements:

    • Proper licences and training certificates.

• E. AAC8e: Imaging results are available within a defined timeframe. (C) [Commitment Level]*

  • Key Concepts:

    • Realistic TAT

      • "Reasonable Timeframe"

  • Requirements:

    • Reviewing any data that can help improve a certain task.

• F. AAC8f: Critical results are intimated immediately to the personnel concerned. (C) [Commitment Level]*

  • Key Concepts:

    • Critical Results

      • "Have a list of all the critical findings".

      • "Call and inform provider"

  • Requirements:

    • Have a way of reporting the documentation of the list and results.

• G. AAC8g: Results are reported in a standardised manner. (C) [Commitment Level]

  • Key Concepts:

    • Documented Reporting:

      • "Standard Reporting": Reporting requirements that must be met.

  • Requirements:

    • Have all templates and requirements organized to be readily accessed.

• H. AAC8h: There is a mechanism to address recall / amendment of reports whenever applicable. (A) [Achievement Level]*

  • Key Concepts:

    • Recall and Amendment of Information

      • "Policy and process for recall": A clearly written statement that explains the process for any changes.

  • Requirements:

    • Reviewing any policies or procedures for inaccuracies

• I. AAC8i: Imaging tests not available in the organization are outsourced to the organization(s) based on their quality assurance system. (C) [Commitment Level]

  • Key Concepts:

    • Quality Assurance:

      • "Contracts and MOUs": The outside vendor meets the standard of the hospital .

  • Requirements:

    • Documents to attest and ensure quality.

IV. Implementation Notes:

• Regularly review and update the list of imaging services to ensure that it reflects the changing needs of the patient population and advancements in technology.

• Staff training should emphasize the importance of radiation safety protocols and the responsible use of imaging technology.

V. Example Resources (Templates & Checklists):

• Imaging Service Scope Document

• Competency Assessment Tool for Imaging Personnel

• Radiation Safety Manual

• Critical Result Notification Policy

• Quality Control Checklist

• Vendor Qualification Checklist

AAC9: There is an established quality assurance and safety programme for safety services

I. Standard Definition:

• AAC9: There is an established quality assurance and safety programme for safety services.

• Underlying Principle: Ensuring a robust quality assurance and safety program for imaging services is paramount for protecting patients, staff, and the environment from potential hazards associated with radiation and other imaging modalities. This includes minimizing radiation exposure, preventing accidents, and ensuring proper equipment function.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC 10 and AAC 11 merged

III. Objective Element Deep Dive:

• A. AAC9a: The quality assurance programme for imaging services is implemented. (C) [Commitment Level]*

  • Key Concepts:

    • Comprehensive QA Program: Implementation of a formal, documented QA program that covers the following:

      • "Equipment Evaluation": Regular testing of equipment.

    • Dosage and Protocol Review

      • "Dosage”: Minimize the dosage required for safe and correct operation.

      • "Professional body guidelines”: Maintain consistency to a professional body.

  • Requirements:

    • Maintain the necessary testing on the equipment to keep it safe.

• B. AAC9b: A system is in place to ensure the appropriateness of the investigations and procedures for the clinical indications. (A) [Achievement Level]

  • Key Concepts:

    • Investigation for Appropriate uses

      • “The use of these systems must be appropriate” : If this not met, this process needs to be reviewed.

      • “Appropriate investigations”: the staff member has done the investigation on the proper location, with the right information to receive an accurate image.

  • Requirements:

    • Must document the required training to the personnel and staff and follow up investigations in radiology.

• C. AAC9c: The programme addresses periodic internal/external peer review of imaging results using appropriate sampling. (A) [Achievement Level]

  • Key Concepts:

    • Review of Imaging

      • "A proper peer review": A team to review if the imaging was effective.

  • Requirements:

    • Team qualifications for peer review.

• D. AAC9d: The programme addresses clinico-radiological meeting(s). (E) [Excellence Level]

  • Key Concepts:

    • Collaboration

      • "Discuss Radiologist": Communicate what you have found, in order to have a review.

  • Requirements:

    • Meeting documentation and minutes.

• E. AAC9e: The programme includes the documentation of corrective and preventive actions. (C) [Commitment Level]*

  • Key Concepts:

    • The Quality Plan to have a documented plan which addresses the following.

  • Requirements:

    • Appropriate actions that are being performed for the patient.

• F. AAC9f: The radiation-safety programme is implemented. (C) [Commitment Level]*

  • Key Concepts:

    • Follow all radiation safety guidelines.

    • Documentation and Maintenance that can be maintained

  • Requirements:

    • Training and following the requirements of state.

• G. AAC9g: Patients are appropriately screened for safety / risk before imaging. (C) [Commitment Level]

  • Key Concepts:

    • “Patient History”

      • Must discuss any pregnancy concerns, or conditions before any imaging or therapy is completed.

  • Requirements:

    • Documentation of when a patient is asked of pre-conditions before the scan or procedure.

• H. AAC9h: Imaging personnel and patients use appropriate radiation safety and monitoring devices where applicable. (C) [Commitment Level]

  • Key Concepts:

    • Documentation of Training

      • Personnel have the required training and can provide documentation.

      • PPE Requirements of each radiation technician, and patient.

  • Requirements:

    • Ensure to have a documentation of those safety requirements are followed.

• I. AAC9i: Radiation-safety and monitoring devices are periodically tested, and results are documented. (C) [Commitment Level]*

  • Key Concepts:

    • Testing Safety Devices:

      • Must test and store equipment in compliance with regulations

  • Requirements:

    • Requirements followed.

• J. AAC9j: Imaging and ancillary personnel are trained in imaging safety practices and radiation-safety measures. (C) [Commitment Level]

  • Key Concepts:

    • Staff Training:

      • Specific to their job function.

  • Requirements:

    • Staff is properly trained.

• K. AAC9k: Imaging signage is prominently displayed in all appropriate locations. (C) [Commitment Level]

  • Key Concepts:

    • The safety and warning protocols are visibly posted for everyone to see.

  • Requirements:

    • All signage is placed visibly and understandable.

IV. Implementation Notes:

• The quality assurance program should be risk-based, focusing on identifying and mitigating potential sources of error and safety hazards.

• Regularly review and update safety policies to ensure that they align with current best practices and regulatory requirements.

V. Example Resources (Templates & Checklists):

• Radiation Safety Manual

• Imaging Equipment Maintenance Schedule

• Personnel Training Log

• Safety Inspection Checklist

• Incident Reporting Form

AAC10: Patient care is continuous and multi-disciplinary 

I. Standard Definition:

• AAC10: Patient care is continuous and multi-disciplinary.

• Underlying Principle: Patient care is optimized when it is seamless across settings and involves a coordinated team of healthcare professionals with diverse expertise. This approach promotes comprehensive assessment, effective communication, and personalized treatment planning.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC 10 was (AAC 12 in 5th edition) : NO CHANGES

III. Objective Element Deep Dive:

• A. AAC10a: During all phases of care, there is a qualified individual identified as responsible for the patient's care. (C) [Commitment Level]

  • Key Concepts:

    • Designated Primary Caregiver:

      • "Medical Care Giver": Must have a primary caregiver that helps the patient with their needs.

  • Requirements:

    • Qualifications of the person who is assigned to care.

• B. AAC10b: Patient care is coordinated in all care settings within the organization. (C) [Commitment Level]

  • Key Concepts:

    • Coordinating Care

      • "Coordinating care": For the patient to have an understanding what will be occurring and what their options are.

  • Requirements:

    • Maintaining communication.

• C. AAC10c: Information about the patient's care and response to treatment is shared among medical, nursing and other care providers. (C) [Commitment Level]

  • Key Concepts:

    • Communication of information

      • "All pertinent information": To keep informed about any treatment plan.

  • Requirements:

    • A plan or method of communicating to each party all information so all can remain informed.

• D. AAC10d: Organisation implements standardised hand-over communication during each staffing shift, between shifts and during transfer between units/departments. (CO) [Core Objective]

  • Key Concepts:

    • Shift Changes

      • "Shift Changes": The personnel are able to discuss cases and any additional recommendations for the patient.

  • Requirements:

    • Ensure the communication is standardized so that all information is the same.

• E. AAC10e: Patient transfer within the organisation is done safely. (C) [Commitment Level]

  • Key Concepts:

    • Internal Transfer:

      • "When there are test results, transfer patients safely": All information about the patient is safe, all parties are informed of transport, and all equipment is ready.

  • Requirements:

    • Safe and proper equipment, and to ensure all test and care data is available for the new team members.

• F. AAC10f: Referral of patients to the other departments/ specialties follow written guidance. (C) [Commitment Level]*

  • Key Concepts:

    • Specialists Available:

      • "The Patient gets seen in a timeframe": So that treatment can be applied quickly.

  • Requirements:

    • Appropriate guidelines that can be tracked and documentation that a specialty doctor can evaluate.

• G. AAC10g: The organisation ensures predictable services delivery by adhering to defined timelines and informs the patient/family and/ or caregiver whenever there is a change in schedule. (A) [Achievement Level]

  • Key Concepts:

    • Timeline for the treatments to be followed

      • "The Care and treatment": Must document what treatments are performed.

  • Requirements:

    • Documentation that those treatments are correct.

• H. AAC10h: The organisation has a mechanism in place to monitor whether adequate clinical intervention has taken place in response to a critical value alert. (E) [Excellence Level]

  • Key Concepts:

    • Critical Value:

      • "The Care Team" The care team knows of all results in order to get them treated properly.

  • Requirements:

    • The organization should have a timeline that is set for clinical and medical personnel.

IV. Implementation Notes:

• Staff training should emphasize the importance of effective communication skills, both verbal and written, to facilitate seamless care transitions.

• Regularly evaluate the effectiveness of multidisciplinary care teams and identify opportunities for improvement.

V. Example Resources (Templates & Checklists):

• Interdisciplinary Care Plan Template

• Communication Log

• Referral Form

• Patient Satisfaction Survey

AAC11: The preventive and promotive and health services are provided in a safe collaborate and consistent manner

I. Standard Definition:

• AAC11: The preventive and promotive and health services are provided in a safe collaborate and consistent manner.

• Underlying Principle: Providing proactive healthcare services is key to preventing diseases and improving patient well-being. It is essential to work within the community needs.

II. Summary of Changes (6th Edition vs. 5th Edition):

• Brand new, as AAC 11

III. Objective Element Deep Dive:

• A. AAC11a: Written guidance governs the implementation of preventive and promotive care as per the scope of services. (C) [Commitment Level]*

  • Key Concepts:

    • Policies and procedures

      • Preventive and promotive care requirements can be met, through policy or procedure, while the service must ensure safe practice.

  • Requirements:

    • Proper documentation with scope of services.

• B. AAC11b: Organisation shall define evidenced based and contextual age appropriate screening for non-communicable diseases. (C) [Commitment Level]

  • Key Concepts:

    • Non-Communicable Disease Standards

      • Proper evidence to have that this will make a beneficial outcome.

  • Requirements:

    • Documentation of a history and how the plan or standards will be met.

• C. AAC11c: Mental health screening and appropriate intervention is advised for patients wherever applicable.(C) [Commitment Level]

  • Key Concepts:

    • Mental Health Screening

      • A documented plan to make sure patients are receiving any possible treatment, with consent of the patient for any screening or treatment.

  • Requirements:

    • A safe plan in order to meet all requirements for the patient.

• D. AAC11d: Evidence based and contextual paediatric and adult immunisation shall be advised wherever applicable. (C) [Commitment Level]

  • Key Concepts:

    • Immunizations

      • "The patients who need it will be receiving it."

  • Requirements:

    • That the immunization schedule will be followed by a nurse and medical personnel.

• E. AAC11e: A multidisciplinary approach is adopted in imparting health education on lifestyle modifications. (C) [Commitment Level]

  • Key Concepts:

    • Team effort

      • "Medical team, and care providers are all on board with providing great education"

  • Requirements:

    • Clear communication and support.

IV. Implementation Notes:

• Collaborate with community partners to extend the reach of preventive and promotive care initiatives.

• Regularly evaluate the effectiveness of these initiatives and adjust strategies based on the data.

V. Example Resources (Templates & Checklists):

• Preventive and Promotive Care Policy Manual

• Screening Protocol for Non-Communicable Diseases

• Mental Health Screening Tool

• Immunization Schedule

• Health Education Materials

AAC12: The organization has an established discharge process 

I. Standard Definition:

• AAC12: The organization has an established discharge process.

• Underlying Principle: A well-defined and implemented discharge process ensures a smooth and safe transition for patients from the hospital setting to their home or another care facility. This process minimizes the risk of adverse events, promotes patient understanding of their ongoing care needs, and supports continuity of care.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC 12 was (AAC 13 in 5th edition) : NO CHANGES

III. Objective Element Deep Dive:

• A. AAC12a: The patient’s discharge process is planned in consultation with the patient and/or family. (C) [Commitment Level]

  • Key Concepts:

    • Collaborative Planning:

      • "Work with Patient and Caregiver": the correct plan to provide safe treatment that works best for them, and understand that this treatment must be maintained at home, and that patients will be ready for the treatment.

  • Requirements:

    • Documentation that patients and caregivers have been included with making the proper medical decision.

• B. AAC12b: Discharge process is coordinated among various departments and agencies involved (Including medico-legal and absconded cases). (C) [Commitment Level]*

  • Key Concepts:

    • Communicating Across Departments

      • "Departments communicate together" to have that the patient is in a place where they will be best served for their needs.

      • "Police notified": if any legal issues must be handled for any patient needs.

  • Requirements:

    • There must be documentations, from both the hospital, departments and police (if needed.)

• C. AAC12c: Written guidance governs the discharge of patients leaving against medical advice. (C) [Commitment Level]*

  • Key Concepts:

    • Risks described

      • "Doctors explain the risks that can happen if a person refuses to be treated": Must inform a patient before the risks that they may have.

  • Requirements:

    • Proper signatures and explanations of what might occur.

• D. AAC12d: A discharge summary is given to all the patients leaving the organisation (including patients leaving against medical advice). (C) [Commitment Level]

  • Key Concepts:

    • Follow the proper guidelines and proper care of patients.

    • Patient Summary.

      • "Patient has a physical report": to provide follow up care information.

  • Requirements:

    • What are the report must contains and when must the patient or personnel contact the doctor to have their assistance.

• E. AAC12e: The organisation adheres to planned discharge. (A) [Achievement Level]

  • Key Concepts:

    • Planned date for discharge.

    • Must be planned and ready for patient, if that is to occur within the 24 hour time.

  • Requirements:

    • Must have the team and location be available to the patient.

• F. AAC12f: The care shall be provided by expanding access to health practices through domiciliary visits wherever applicable. (A) [Achievement Level]

  • Key Concepts:

    • Home Care plan

      • "The Patient has care in home": To ensure that patient understands to continue care requirements, if they have the treatment or procedures needed to maintain that level of care.

  • Requirements:

    • Check in with the patient to make sure all requirements is being completed.

• G. AAC12g: The organisation monitors the discharge time sets appropriate benchmarks and makes continual Improvement.(C) [Commitment Level]

  • Key Concepts:

    • Evaluate each case.

      • "What occurs in order to help speed up the process, what makes patients upset, what is done correctly."

  • Requirements:

    • Meeting documents and discussion.

IV. Implementation Notes:

• Ensure that the discharge planning process begins early in the patient's stay, preferably at the time of admission.

• Staff training should emphasize the importance of patient education and empowerment in promoting successful transitions of care.

V. Example Resources (Templates & Checklists):

• Discharge Planning Policy and Procedure Manual

• Discharge Summary Template

• Medication Reconciliation Form

• Patient Education Materials

• Community Resource Directory

• Discharge Time Tracking Tool

AAC13: Organisation defines the content of the discharge summary

I. Standard Definition:

• AAC13: Organisation defines the content of the discharge summary.

• Underlying Principle: A standardized and comprehensive discharge summary ensures that patients and their subsequent care providers have access to essential information about their hospital stay, ongoing care needs, and potential complications. This facilitates continuity of care and minimizes the risk of adverse events.

II. Summary of Changes (6th Edition vs. 5th Edition):

• AAC 13 was (AAC 14 in 5th edition) : NO CHANGES

III. Objective Element Deep Dive:

• A. AAC13a: A discharge summary is provided to the patients at the time of discharge. (C) [Commitment Level]

  • Key Concepts:

    • At time of discharge:

    • Signatures:

      • "All patients must sign off for": That they have received discharge paperwork.

  • Requirements:

    • Must have a signed form from patient and caregiver.

• B. AAC13b: Discharge summary as a standardised content. (C) [Commitment Level]

  • Key Concepts:

    • "Content Requirements"

      • The Patient’s medical and care that they have received.

  • Requirements:

    • All medical terms should be simplified

• C. AAC13c: Discharge summary contains follow-up advice, medication and other instructions in an understandable manner. (C) [Commitment Level]

  • Key Concepts:

    • Medical instructions to perform at home with the right requirements

  • Requirements:

    • Ensure all content follows all compliance rules for state and medical personnel.

• D. AAC13d: Discharge summary incorporates instructions about when and how to obtain urgent care. (C) [Commitment Level]

  • Key Concepts:

    • In order to continue care in the right timeline and right requirements:

      • Document contact numbers.

  • Requirements:

    • Make sure all patients and caregivers understand how to receive proper care.

• E. AAC13e: In case of death, the summary of the case also includes the cause of death. (C) [Commitment Level]

  • Key Concepts:

    • What were the contributing reasons:

      • "Document reasons for a medical examiner."

• • Requirements:

    • Follow all guidelines.

IV. Implementation Notes:

• Involve a multidisciplinary team in developing the standardized content of the discharge summary to ensure that all essential information is included.

• Regularly review and update the discharge summary template to reflect changes in clinical practice and regulatory requirements.

V. Example Resources (Templates & Checklists):

• Standardized Discharge Summary Template

• Checklist for Discharge Summary Content

• Patient Education Materials

• Medication List Template

Focus Areas Within the Standards (AAC)

Purpose: This section highlights recurring themes and critical focus areas that span across multiple AAC standards. Understanding these broader themes will help trainees prioritize their efforts, identify potential gaps, and implement holistic solutions.

Key Focus Areas & Training Considerations:

1. Patient Safety:

• Underlying Principle: Patient safety is the overarching priority of all AAC standards. Every process, policy, and action should be evaluated through the lens of patient safety.

• Examples from Standards:

  • AAC2: Safe bed allocation.

  • AAC3: Safe transfer.

  • AAC4: Safety measures related to treatment.

  • AAC7: Safety of Lab Personnel.

  • AAC9: Safety measures in imaging to minimize risks to patients.

  • AAC10: Safe transfers within the organizations.

• Training Focus:

  • Risk Assessment Training: Equip staff with the skills to identify and assess potential risks at each stage of the patient journey.

  • Root Cause Analysis: Train staff on how to conduct root cause analyses to investigate adverse events and implement corrective actions.

  • Error Prevention Strategies: Implement strategies such as checklists, double-checks, and standardized protocols to minimize the risk of human error.

2. Accessibility and Timeliness of Care:

• Underlying Principle: Providing timely and equitable access to appropriate healthcare services is essential for preventing delays in diagnosis, treatment, and improving patient outcomes.

• Examples from Standards:

  • AAC1: Clearly defining and displaying hours of operation for services.

  • AAC2: Patient priority.

  • AAC5: Prioritization and Reassessment.

  • AAC6: Reporting and documentation has a time frame to complete.

  • AAC8: Availability of results.

  • AAC10: Time to be seen and timeline for appointments.

• Training Focus:

  • Time Management Techniques: Implement methods to effectively manage patient flow.

  • Community Outreach:

    • Training with what the organizations can do for the community.

• • Patient Education:

    • The importance of check ups.

3. Interdisciplinary Collaboration and Communication:

• Underlying Principle: Effective communication and collaboration among healthcare professionals from different disciplines are crucial for providing coordinated and comprehensive patient care.

• Examples from Standards:

  • AAC4: Care team is required to be on board with assessment plans.

  • AAC7: Collaborative meetings.

  • AAC10: Care has all levels and parts to help provide the best care to the patient.

  • AAC11: Collaboration.

• Training Focus:

  • Communication Skills Training: Implement communication techniques that are taught to personnel.

  • Team Building Activities: Incorporate team building activities to facilitate effective team dynamic and the team's ability to solve problems.

4. Documentation and Record Keeping:

• Underlying Principle: Accurate and complete documentation is essential for communicating patient information, supporting clinical decision-making, and demonstrating compliance with regulatory requirements.

• Examples from Standards:

  • AAC6: Recording process.

  • AAC7: Testing is performed accurately.

  • AAC8: Reporting.

  • AAC 10: All communication is documented.

  • AAC 12: All departments and agencies involved must communicate and record.

• Training Focus:

  • Documentation Standards Training: Provide all staff to work properly and correctly.

  • Documentation Audits: Periodic reviews.

5. Patient Education and Empowerment:

• Underlying Principle: Empowering patients with knowledge and skills to manage their own health is essential for promoting adherence to treatment plans, preventing complications, and improving overall outcomes.

• Examples from Standards:

  • AAC5: Communication on best practice.

  • AAC10: Educating.

  • AAC11: Education on lifestyle.

  • AAC12: Patient education on what will be done.

• Training Focus:

  • Communication Skills: Learn how best to explain complex information.

6. Community Integration and Continuity of Care:

• Underlying Principle: A hospital should work with community and other care systems to improve the overall treatment of patients and safety.

• Examples from Standards:

  • AAC1: Communication with community.

  • AAC3: Partner organizations.

  • AAC10: Handover and ongoing patient care.

  • AAC11: How lifestyle adjustments can be made.

  • AAC12: Home Treatment and follow up care.

• Training Focus:

  • Communication Skills: Learn how best to explain complex information.