This document must be provided to patients to inform them of their care options and responsibilities.
What is the Patient Rights and Responsibilities policy?
The AAAHC requires organizations to have this type of plan to monitor and improve care.
What is quality improvement (QI) plan?
This type of plan outlines emergency response procedures.
What is an Emergency Preparedness Plan?
These must be used during procedures to protect both patients and staff.
What are standard precautions (e.g., gloves, masks)?
This group has ultimate responsibility for the organization's operations and quality.
What is the governing body or board?
Patients have the right to this before undergoing any procedure.
What is informed consent?
This is used to analyze trends in care, outcomes, and safety.
What is performance data?
This must be maintained to ensure clean and functional equipment.
What is preventive maintenance?
This process destroys all microbial life, including spores.
What is sterilization?
The organization must maintain these to document policies and procedures.
What are administrative manuals or handbooks?
This right allows patients to refuse treatment, even if it may affect their health.
What is the right to refuse care?
Staff must regularly participate in these to ensure ongoing competency.
What are education and training programs?
Staff must conduct these drills at least annually, but most are conducted quarterly.
What are fire or evacuation drills?
AAAHC requires these policies to prevent the spread of infectious diseases.
What are infection prevention and control policies?
These are required for credentialing and privileging clinical staff.
What are current licensures and certifications?
Organizations must protect patient information according to this federal regulation.
What is HIPAA?
These assessments compare performance against best practices or national benchmarks.
What are quality indicators or benchmarks?
AAAHC requires that these be conducted to identify risks in the physical environment.
What are safety or hazard assessments?
This item must be documented after each sterilization cycle.
What is a sterilization log or record?
AAAHC requires the organization to comply with these, which may vary by state.
What are applicable laws and regulations?
Patients must be informed of these non-clinical factors that may influence their care, such as financial interests.
What are conflicts of interest?
The results of QI activities must be shared with this group for review and action.
What is the governing body or leadership?
All chemicals used must be labeled and tracked according to this OSHA regulation.
What is the Hazard Communication Standard?
Staff must receive training on infection control at this frequency.
What is annually (at minimum)?
This document is a written plan that outlines the mission, values, and objectives of the organization.
What is the strategic plan or mission statement?