Patient Rights & Responsibilities
Quality of Care Provided
Environment of Care & Safety
Infection Prevention & Control
Governance & Administration
100

This document must be provided to patients to inform them of their care options and responsibilities.

What is the Patient Rights and Responsibilities policy?

100

The AAAHC requires organizations to have this type of plan to monitor and improve care.

What is quality improvement (QI) plan?

100

This type of plan outlines emergency response procedures.

What is an Emergency Preparedness Plan?

100

These must be used during procedures to protect both patients and staff.

What are standard precautions (e.g., gloves, masks)?

100

This group has ultimate responsibility for the organization's operations and quality.

What is the governing body or board?

200

Patients have the right to this before undergoing any procedure.

What is informed consent?

200

This is used to analyze trends in care, outcomes, and safety.

What is performance data?

200

This must be maintained to ensure clean and functional equipment.

What is preventive maintenance?

200

This process destroys all microbial life, including spores.

What is sterilization?

200

The organization must maintain these to document policies and procedures.

What are administrative manuals or handbooks?

300

This right allows patients to refuse treatment, even if it may affect their health.

What is the right to refuse care?

300

Staff must regularly participate in these to ensure ongoing competency.

What are education and training programs?

300

Staff must conduct these drills at least annually, but most are conducted quarterly.

What are fire or evacuation drills?

300

AAAHC requires these policies to prevent the spread of infectious diseases.

What are infection prevention and control policies?

300

These are required for credentialing and privileging clinical staff.

What are current licensures and certifications?

400

Organizations must protect patient information according to this federal regulation.

What is HIPAA?

400

These assessments compare performance against best practices or national benchmarks.

What are quality indicators or benchmarks?

400

AAAHC requires that these be conducted to identify risks in the physical environment.

What are safety or hazard assessments?

400

This item must be documented after each sterilization cycle.

What is a sterilization log or record?

400

AAAHC requires the organization to comply with these, which may vary by state.

What are applicable laws and regulations?

500

Patients must be informed of these non-clinical factors that may influence their care, such as financial interests.

What are conflicts of interest?

500

The results of QI activities must be shared with this group for review and action.

What is the governing body or leadership?

500

All chemicals used must be labeled and tracked according to this OSHA regulation.

What is the Hazard Communication Standard?

500

Staff must receive training on infection control at this frequency.

What is annually (at minimum)?

500

This document is a written plan that outlines the mission, values, and objectives of the organization.

What is the strategic plan or mission statement?