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Accreditation FAQ's
Grab Bag
Quality
Survey Scenarios
Survey Logistics
100
How often do we have to do this?
Every three years, and any time we are selected for a random survey
100
When did TCC first become accredited by AAAHC?
2013
100
What is our customer service model?
AIDET (must include acronym): Acknowledge, Introduce, Duration, Explanation, Thank You
100
A surveyor asks you a question about TCC's process/policy for incident reporting on medication errors. You don't know the answer. How should you respond to the surveyor?
"I don't know the answer to that question, but I know where to find it." (Just make sure you do actually know how to find the policy!)
100
What are the dates of the 2016 accreditation survey?
August 8-9
200
What is accreditation anyway?
The process organizations go through with external evaluators who are experts in their fields to ensure that the organization is following best practices and national standards for safety and quality of care.
200
What do the acronyms RACE and PASS stand for?
Rescue, Activate, Confine, Evacuate/Extinguish; Pull, Aim, Squeeze Sweep
200
How often must clinical competencies be completed for clinical staff?
Annually
200
A surveyor tells you that you're performing one aspect of a clinical task incorrectly (i.e sterilization, lab QC, registering a patient, suturing a wound, etc.), and you disagree. What is the best response to the surveyor?
Anything polite and non-argumentative. When in doubt, defer to your supervisor.
200
Which Health Services divisions/programs will be reviewed during the survey?
All of them!
300
What does AAAHC stand for?
Accreditation Association for Ambulatory Health Centers
300
Where do you find information about chemicals used in the workplace?
SDS sheets (found on the intranet main page under "miscellaneous" - second item)
300
To whom should you report quality of care concerns?
Your supervisor or someone in the Quality Department
300
It is the morning of the survey, and you happen to find a piece of biomedical equipment with an expired sticker on it (this is a fictional scenario, of course. Biomed rocks!). What do you do?
If the equipment is portable and there is more than one unit, tag and leave at the biomed office. If it is not portable or is the only unit of its type, contact biomed and your supervisor.
300
What might they look at while they are here?
Many answers: Policies, buildings, biomedical equipment, personnel files, credentialing files, a patient procedure, EHR documentation for multiple types of patients (OB, cancer, CVD, peds, asthma, etc.)
400
Why does accreditation matter (WHY BOTHER???)
Lots of answers: Our patients and tribal members have indicated they want care provided at accredited facilities; it shows we are following national standards and best practices; tells people we are having reviews by external agencies to demonstrate our quality; helps us stay current on industry standards; makes our care better by following those standards; outside eyes help us figure out where we can make improvements on things we might not realize are ineffective...
400
Name two things you can do in your particular area to help prepare for the survey (state your area when you answer the question)
Varies based on area: everyone can review the Health Services policies and safety codes and make sure their areas are clean and tidy prior to the survey.
400
Who is the person responsible for quality in Health Services?
You are! Quality and safety are everyone's responsibility.
400
What is the appropriate response to a surveyor who asks you a complicated, scenario-based question to which you do not know the answer (example: what is the appropriate response when you have three codes called at the same time?)
Something along the lines of "I've never seen that happen before, but if it did, I would ask my supervisor for guidance..."
400
Which clinics are included?
CAIHC, Nenana, Tok North, Tok South, Galena (Nenana will not be surveyed due to time constraints)
500
What's the difference between being accredited and just doing a good job?
Ensures we stay up to date with industry standards in patient safety and quality by providing updates to standards; is a seal of approval from an internationally recognized organization; allows us to benchmark our performance with other clinics through the AAAHC standards. Guy Fieri example...
500
What will happen if we don't meet every single one of the AAAHC standards?
If we are non-compliant on only a few relatively minor issues, we will still likely pass the accreditation survey. If we are non-compliant on many standards, or if we are non-compliant on critical patient-safety standards, our entire organization could be at risk of losing our current accreditation (we are surveyed as an organization, not facility by facility).
500
In which document can you find the policy on hand washing?
Infection Control Manual
500
A surveyor wants to see AIDET in action, and you've just made contact with a patient. Give an example of what you would say to the patient based on your clinical role (must include managing up!)
AIDET demo
500
What questions will the surveyors ask us?
Many answers: May ask you to find/show them a policy on "x" (handwashing, procedures, standing orders, dress code, etc.); may ask who is responsible for restocking supplies or the crash cart; may ask scenario based questions around codes; may ask how you report a medication error; may ask how complicated patients are tracked; may ask to be shown a patient registry; may ask to watch instruments be sterilized...etc.