Accreditation Handbook. For FEHB Health Plans

Transcription

1 Accreditation Handbook 2017 For FEHB Health Plans

2 OUR MISSION IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION 5250 Old Orchard Road, Suite 200, Skokie, IL Website: Phone: The 2017 Accreditation Handbook for FEHB Health Plans, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system now known or to be invented, without written permission from AAAHC, except in the case of brief quotations embodied in critical articles or reviews. For further information, contact AAAHC at the address above. The pronouns used in the Handbook were chosen for ease of reading. They are not intended to exclude references to either gender.

3 Foreword January 2017 Thank you for choosing the AAAHC Handbook for FEHB Health Plans as your resource for accreditation. AAAHC has been accrediting healthcare organizations since 1979 and health plans since In 2015, we were recognized by the Office of Personnel Management (OPM) to meet the specific accreditation needs of Federal Employee Health Benefit (FEHB) plans. The AAAHC Health Plan Advisory Committee along with AAAHC staff and key stakeholders built this FEHB-focused accreditation program to capture the unique characteristics of these plans while maintaining the strength of comprehensive health plan accreditation. FEHB plans that meet the eligibility criteria also have the option to use the AAAHC accreditation program for general health plans. The Standards, policies and procedures for these plans, are found in the 2017 edition of the Accreditation Handbook for Health Plans. This handbook presents a comprehensive overview of the AAAHC accreditation process and our Standards. It is formatted as a series of tools to help you assess your business operations. The Standards are presented topically in Core Chapters (1-8) that apply to all FEHB plans. Each Standard is followed by against which the organization will be assessed, and a compliance scoring table. While no additions were made to the Standards for 2017, the entire handbook has been reviewed and edited for minor corrections and updates. In addition to the Core Chapters, this handbook includes a Tools section with sample copies of tools AAAHC surveyors will use when reviewing personnel, credentialing, and clinical records. Use these along with the to help you evaluate and prepare your organization for the accreditation survey. AAAHC brings a committed team of surveyors and staff who believe that healthcare accreditation drives quality. Over the years, we have developed and promoted Standards that guide health plans in a patient-centered approach to managing utilization and ensuring quality. Becoming accredited through AAAHC promotes a culture of quality based on a rigorous, relevant, peer-based program with a focus on education and consultation. Please feel free to contact our health plans program staff at any time. We are ready to work with you throughout the process to help support your success in achieving and maintaining accreditation. Meena Desai, MD AAAHC Board Chair 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. i

4 Acknowledgments We gratefully acknowledge the efforts of the AAAHC Board of Directors, the Standards and Survey Procedures Committee, and the Health Plan Advisory Committee. Standards and Survey Procedures Committee David M. Shapiro, MD, Chair Tallahassee, FL Dennis Schultz, MD, MSPH, FACOEM, Vice-Chair Franklin, WI Larry Kim, MD, Vice-Chair Lone Tree, CO Edward Bentley, MD, FACP, FACG Santa Barbara, CA Karen W. Connolly, RN Birmingham, MI W. Patrick Davey, MD, MBA Lexington, KY Jan Davidson, MSN, RN, CNO, CASC Aurora, CO Gerald Fleischli, MD Creswell, OR Christine S. Gallagher, RN, BSN, CNOR Salinas, CA David Gans, FACMPE East Englewood, CO Susan Griffin, MSM Tampa, FL Margaret Haecherl, RN, MSN, CNOR, PHN Nashville, TN Dave Hamel, DDS Marysville, KS Irving Hirsch, DDS Highland Heights, OH Sandra Jones, LHRM, MBA, CASC Dade City, FL Girish Joshi, MD Plano, TX Bonnie Petty, FNP, MPH, CPNP Thendara, NY Alyson Roby, MD Valleyford, WA Kenneth M. Sadler, DDS, MPA, FACD Winston-Salem, NC Edwin Slade, DMD, JD Doylestown, PA Benjamin Snyder, FACMPE San Diego, CA Staff Liaisons Cheryl Pistone, RN, MBA Clinical Director Mona Sweeney, RN, BSN Assistant Director, Primary Care and Medical Home Tess Poland, RN, MSN Vice President, Ambulatory Operations Meg Kerr, MPA Vice President, Education and Development 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. ii

5 Acknowledgments Health Plan Advisory Committee Karen W. Connolly, RN, Chair Birmingham, MI Marshall M. Baker, MS, FACMPE Boise, ID James W. Banks, RN Fullerton, CA Lyndell Brooks, FACMPE, MS Penhook, VA Jack Egnatinsky, MD Christiansted, VI Joy Himmel, PsyD, PMNCNS-BC, LPC Chesapeake, VA Jane Baker Lawrence, RN, BS, CPHQ, CPCS Cocoa Beach, FL Timothy Peterson, MD Scottsdale, AZ Dennis Roy, RN, MBA Fort Lauderdale, FL Thomas Thorsness, RN Altoona, WI Staff Liaisons Tom Tassone, MSW Director, Health Plan Accreditation Without the dedication and commitment of these individuals, this edition would not have been possible ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. iii

6 Contents Foreword i Acknowledgments...ii AAAHC Policies and Procedures Introduction... 1 AAAHC Standards... 1 Application of the Standards... 1 Applicable Version of the Standards... 1 Comments and Suggestions about the Standards... 1 Applying for an Accreditation Survey... 2 Survey Eligibility Criteria... 2 Obtaining an Application for Survey... 2 Survey Fees... 3 Scheduling... 3 Postponement... 3 Cancellation Policies... 4 Types of Surveys... 4 Initial Accreditation Survey... 4 Re-accreditation Surveys... 4 Interim Surveys... 4 Random Surveys... 4 Discretionary Surveys... 5 The Accreditation Process: Before the Survey... 5 Pre-Survey Responsibilities of the Applicant Organization... 5 Pre-Survey Public Notice of Accreditation Survey... 5 The Accreditation Process: The On-Site Survey... 6 Surveyor Conduct During a Survey... 7 Conduct of provider medical record review and audit... 7 Additions to the Survey Team... 7 The Accreditation Process: After the Survey... 7 Accreditation Decision and Notification... 7 Term of Accreditation... 8 Must Fully Meet Standards... 9 Plan For Improvement... 9 Interim Survey... 9 Denial or Revocation of Accreditation... 9 Reasons for Denial or Revocation... 9 Appeal of Accreditation Decision... 9 Limitations on Other Rights Public Recognition ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. iv

7 Contents Continuation of Accreditation Continuation of Accreditation Following a Significant Change End of Accreditation Compliance with Omnibus Reconciliation Act of Standards 1. Member Rights, Responsibilities, and Protections Governance Administration Provider Network Credentialing Network Adequacy Case Management and Care Coordination Health Education & Wellness Promotion Quality Improvement and Management I. Quality Improvement Program II. Risk Management Summary Table Tools Sample Application for Privileges Credentialing Records Worksheet Personnel Records Worksheet Resources for Credentials Verification Appendices Appendix A: Organization s Right of Appeal Following Denial or Revocation of Accreditation...81 Appendix B: AAAHC Timeline Appendix C: Members and Leadership ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. v

8 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. vi

9 AAAHC Policies and Procedures

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11 AAAHC Policies and Procedures Introduction AAAHC promotes safe, high-quality patient care and measurement of performance through accreditation. To help organizations achieve nationally-recognized standards, and to recognize these achievements, AAAHC has developed the health plan accreditation program described in this handbook. FEHB health plan organizations are invited to review the policies and Standards in this publication, before applying for an accreditation survey. AAAHC Standards The Standards in the 2017 Accreditation Handbook for FEHB Health Plans describe characteristics that AAAHC believes to be indicative of an accreditable FEHB health plan. Most Standards are written in general terms to allow an organization to achieve compliance in the manner that is most compatible with its particular situation and most conducive to high-quality care for its members. Where the acceptable methods of achieving compliance with a Standard are limited, the Standard is written in specific terms. Whether a Standard is stated in general or specific terms, AAAHC is primarily concerned about compliance with the intent of the Standard. Individual Standards may include multiple elements and sub-elements. describe what a surveyor will look for to demonstrate compliance with each aspect of a Standard and are followed by the scoring rubric used to assess the level of overall compliance with each Standard. Application of the Standards The Standards will be applied to all FEHB health plans seeking accreditation. Throughout this handbook, reference is made to specific documents or standards published by other organizations. Subsequent editions of these publications become the authoritative reference of AAAHC only after they have been approved as such by the AAAHC Board of Directors. All organizations seeking FEHB accreditation, regardless of name, mission statement, or primary service provided, must meet the same Standards described in this handbook. Applicable Version of the Standards An organization will be surveyed according to the 2017 Standards if the FEHB Health Plan Application for Survey is received at the AAAHC office on or after January 1, Comments and Suggestions about the Standards AAAHC welcomes comments or suggestions at any time regarding the reasonableness or clarity of any of the Standards. These comments and suggestions should be sent to info@aaahc.org. The Standards are reviewed annually by the Standards and Survey Procedures Committee for ongoing relevance and applicability. All revisions, additions, or deletions are subject to a public comment period of 30 calendar days. Proposed changes for the next year are available for review throughout the public comment period announced at AAAHC solicits and invites comments regarding the proposed annual changes to the Standards from the Health Plan Advisory Committee, member organizations, accredited health plans, accredited FEHB health plans, and all other interested parties. After considering recommendations from the Health Plan Advisory Committee, the Standards and Survey Procedures Committee submits any proposed revisions, deletions, or additions to the existing Standards, all relevant public comments received, and any other recommendations in response to the comments to the AAAHC Board of Directors for review and final approval ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 1

12 AAAHC Policies and Procedures Applying for an Accreditation Survey Survey Eligibility Criteria Organizations are considered for survey by AAAHC on an individual basis. FEHB health plan organizations are eligible if they meet all of the following criteria. The organization: 1. Is a formally organized and legally constituted entity recognized by OPM as a health benefits plan carrier, under the oversight of a physician. 2. Is in compliance with applicable federal, state, and local laws and regulations, or for organizations operating outside of the United States, all applicable laws and regulations. 3. Operates in compliance with the U.S. Equal Employment Opportunity Commission laws. 4. Submits the completed, signed FEHB Health Plan Application for Survey, all supporting documents, and application fee in advance of the survey. 5. Pays the appropriate fees in accordance with AAAHC policies; see Survey Fees, on page Acts in good faith in providing complete and accurate information to AAAHC during the accreditation process and throughout the term of accreditation. AAAHC reserves the right to reject any application. If AAAHC determines that the Standards cannot be applied, a survey will not be conducted and AAAHC will inform the organization of the reason for such a decision. If a survey is conducted and AAAHC determines that the Standards cannot be appropriately applied in order to reach an accreditation decision, the survey will be deemed to be a consultation and no accreditation decision will be made. Fees for such a consultation will not be refunded. Obtaining an Application for Survey Visit to access the Health Plan Application for Survey and for further information. The electronic application is completed by all organizations seeking accreditation. The application requires an organization to attest to its compliance with the Survey Eligibility Criteria. By signing the application, the organization 1) attests to the accuracy and veracity of the statements in the application, and of other information and documents provided to AAAHC and to the survey team during the survey process; 2) agrees to comply with all applicable AAAHC policies and procedures; and 3) understands that AAAHC may use the information supplied in the application and information collected during the survey for quality improvement purposes. Such information will not be identified by organization. A survey will only be scheduled after an organization s completed application, all supporting documents, and the non-refundable application fee have been received by the AAAHC office. AAAHC staff will review the application and may request clarification of any information contained therein or additional information before a survey is scheduled. An application is valid for six months from the date of its receipt by AAAHC. If the organization does not schedule a survey during the six-month period, the application will expire and the organization must submit a new application, including a new application fee. A note about delegation For the purposes of the AAAHC FEHB accreditation program, delegation is defined as a formal process by which an organization gives another organization the authority to perform certain administrative functions on its behalf, such as credentialing, utilization management, and quality improvement. Although the FEHB organization can delegate the authority to perform a function, it cannot delegate the responsibility for ensuring that the function is performed appropriately and in compliance with AAAHC Standards. The organization fulfills its responsibility and exercises its authority by providing oversight of the delegate ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 2

13 AAAHC Policies and Procedures A note about confidentiality AAAHC will maintain as confidential all information provided to it with respect to any organization that is seeking or has obtained accreditation; will use such information solely for the purposes of reaching an accreditation decision; and will not disclose such information to any third party except (1) on prior written authorization from the organization; (2) as otherwise provided in the Handbook; or (3) as otherwise required by law or agreement with a state or federal regulatory authority. In submitting its signed application, the organization either provides or authorizes AAAHC to obtain required official records and reports of public or publicly-recognized licensing, examining, reviewing, or planning bodies. In the event that AAAHC determines that a health plan has supplied false, misleading, or incomplete information, AAAHC reserves the right to disclose information about the plan in order to obtain accurate or complete information. Survey Fees The application fee is the same for all organizations. The survey fee is determined by AAAHC from information submitted in the Health Plan Application for Survey and its supporting documentation. Factors considered in determining survey fees include the complexity, type, and range of services provided by the health plan. An invoice will be sent when the application is accepted as complete. Except where prohibited by law, the survey fee must be paid in full not later than 20 calendar days prior to the survey start date or 20 calendar days from receipt of the invoice, whichever is later. Failure to pay the survey fee in advance will result in cancellation of the survey. Scheduling Survey dates are scheduled by AAAHC in cooperation with the organization being surveyed. Every attempt is made to schedule the survey at a convenient time for the requesting organization. Postponement A request to postpone a scheduled survey must be received by the AAAHC office in writing. Application fees are non-refundable. For postponement due to any circumstance, the organization will be responsible for all direct and indirect non-refundable costs associated with delaying the survey, including, but not limited to, costs incurred for surveyor transportation and lodging. If an organization postpones a scheduled survey a second time, additional fees will be assessed at the discretion of AAAHC, and the fees must be paid prior to rescheduling the survey. If an organization requests a postponement more than twice, AAAHC will cancel the survey and organization will be required to submit a new application, supporting documents and pay another survey fee. The following fee schedule applies to postponed surveys: Once a survey has been scheduled, AAAHC sends a written confirmation of the date(s) of the survey, the name(s) of the surveyor(s) who will be on-site, the survey agenda, and other information about what to expect prior to and during the survey. Contact AAAHC with questions about your scheduled survey. Occurrence First (any time prior to the survey) Second (any time prior to the survey) Survey Fee Any costs that are incurred due to the change Any costs that are incurred due to the change Administrative Fee None $500 Third (survey will be cancelled) Any costs that are incurred due to the change $ ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 3

14 AAAHC Policies and Procedures Cancellation Policies A request for cancellation of a scheduled survey must be received by the AAAHC office in writing. Application fees are non-refundable. If an organization cancels its survey 20 calendar days or more before the scheduled start date of the survey, the survey fee will be refunded, less all direct and indirect nonrefundable costs including, but not limited to, the cost of surveyor transportation and lodging. If the organization cancels its scheduled survey 10 to 19 calendar days before the scheduled survey start date, the survey fee will be refunded, less all direct and indirect nonrefundable costs including, but not limited to, the cost of surveyor transportation and lodging. AAAHC will also assess a $500 administrative fee. If the organization cancels its survey fewer than ten calendar days before the start of the scheduled survey, no refunds or credits will be given. If an organization cancels a scheduled survey more than once, additional fees will be assessed at the discretion of the AAAHC, and the fees must be paid prior to scheduling the next survey. All accounts must be paid in full prior to scheduling the next survey. The following fee schedule applies to cancelled surveys: Calendar Days Before Survey Start Date 20 days or more days <10 days Application Fee No refund No refund No refund Survey Fee Full refund, less incurred costs Full refund, less incurred costs No refund Administrative Fee None $500 None NOTE: Accreditation decisions and survey reports are not released to an organization with an outstanding invoice. Types of Surveys FEHB health Plans are surveyed as follows: Initial Accreditation Surveys Initial Accreditation Surveys are conducted for organizations that are not currently accredited by AAAHC. Re-accreditation Surveys Re-accreditation Surveys are conducted for organizations that are currently AAAHC-accredited and seek continuation of accreditation. See Continuation of Accreditation on page 10 for additional information. Interim Surveys Interim Surveys are conducted for organizations that are currently AAAHC-accredited and for which oversight is required to assess ongoing compliance with the accreditation Standards. The organization will be informed of the need for an interim survey following review of the organization s Plan for Improvement (PFI). See Plan for Improvement on page 9 and Continuation of Accreditation for additional information. The organization will be assessed a fee for an Interim Survey. Random Surveys To support ongoing AAAHC quality improvement initiatives, an accredited organization may be selected for a Random Survey from nine to 30 months after an accreditation survey. Random Surveys are unannounced. Organizations are selected on a proportionate basis across settings and geographic areas. These surveys, which are conducted by one surveyor and may last one full day, are a means by which AAAHC can evaluate the consistency and quality of its program, while also demonstrating to the public and to regulators that accredited organizations remain committed to AAAHC Standards throughout the accreditation cycle. Random Surveys also provide AAAHC and its surveyors with opportunities to further consult with accredited organizations in the interval between regular surveys. No fee shall be charged to the organization when a Random Survey is conducted. If, as a result of a Random Survey, AAAHC determines that the organization is not in substantial compliance with the Standards, the organization s accreditation term may be reduced or revoked. (Refer to Denial or Revocation of Accreditation, page 9, and Appendix A, page 81.) Following a Random Survey, the organization will receive an accreditation decision letter and a survey report ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 4

15 AAAHC Policies and Procedures Discretionary Surveys Discretionary Surveys are conducted for cause, when concerns have been raised about an accredited organization s continued compliance with the Standards. An accredited organization may undergo a Discretionary Survey at any time, without advance notice, and at the discretion of AAAHC. A fee may be charged to the organization when a Discretionary Survey is conducted. If, as a result of the Discretionary Survey, AAAHC determines that the organization is not in substantial compliance with the Standards, the organization s accreditation term may be reduced or revoked. (Refer to Denial or Revocation of Accreditation, and Appendix A.) Following a Discretionary Survey, the organization will receive an accreditation decision letter and a survey report. The Accreditation Process: Before the Survey Each accreditation survey is tailored to the type, complexity, and range of services offered by the organization seeking accreditation. The length of the on-site visit and the number of surveyors sent by AAAHC is based on membership, the number of delegates, and a review of the information provided in the Health Plan Application for Survey and supporting documents submitted by the organization. Questions regarding the scope of a survey should be directed to the AAAHC office before the survey. Pre-Survey Responsibilities of the Applicant Organization Information provided by an organization seeking accreditation or re-accreditation is a critical component of the assessment process. The accuracy and veracity of that information is essential to the integrity of AAAHC accreditation. Such information may be verbal in nature, obtained through direct observation by AAAHC surveyors, or derived from documents supplied by the organization. AAAHC requires that each organization enter into the accreditation relationship in good faith. Failure to participate in good faith during the accreditation process and during any subsequently awarded term of accreditation, including, but not limited to, the submission of falsified, inaccurate, or incomplete documents or information, or failure to pay applicable fees, may be grounds for denial or revocation of an organization s accreditation status; for terminating an application or an appeal; or for ceasing to do business with the organization. When an organization fails to act in good faith, it forfeits its right to appeal of any such action by AAAHC. In the event that an application or appeal process is terminated, AAAHC is entitled to retain the application and survey fees or any other applicable fees paid by the organization. An organization s duty to provide complete and accurate information continues throughout the entire accreditation experience. If an organization undergoes significant changes after it submits its application, but before an accreditation decision is reached, the organization must notify AAAHC in writing within five business days of this change. Failure to notify AAAHC promptly may result in immediate termination of an application or immediate revocation of accreditation. Pre-Survey Public Notice of Accreditation Survey During the on-site survey, AAAHC provides an opportunity for members of the general public, as well as health plan members and staff of the organization, to present relevant information about the surveyed organization s coordination of health care or its compliance with the AAAHC Standards. Alternatively, individuals may present such information in writing to the AAAHC office. All information received from individuals will be considered for relevance and accuracy, and considered in the accreditation process. The findings may be included in the survey report, if relevant. For all types of surveys (except Random and Discretionary Surveys), AAAHC policy requires that a Notice of Accreditation Survey (including the date(s) of the survey and an invitation for individuals to present relevant information) be provided to staff of the health plan, to members of the plan, to delegates of the plan, and to both employed and contracted providers. To assist organizations and to ensure consistency in this process, AAAHC sends copies of the Notice of Accreditation Survey form to each organization for public posting and distribution. The health plan may photocopy the notice in order to achieve wide distribution and visibility. The notice must be distributed and available for 30 calendar days before the scheduled survey start date. In the event that confirmation of the scheduled survey is available fewer than 30 calendar days before the survey starts, the notice must be publicly available for a total of 30 calendar days. The notice may be distributed in various ways (e.g., announcement in the member or provider newsletter, special bulletins distributed to staff, members, or providers or an advertisement in the local newspaper). FEHB health plans may use other means of notification, but are advised to obtain prior approval from AAAHC to ensure that requirements of the policy are met ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 5

16 AAAHC Policies and Procedures If the notice is not distributed, the survey will be conducted, but no accreditation decision will be made until the FEHB health plan makes the notice publically available for a period of 30 calendar days. If the notice is not posted and a request to present relevant information is received by AAAHC, a surveyor may be sent, at the surveyed organization s expense, to receive the information. A request to present information during the on-site survey must be received by the AAAHC office at least two weeks before the survey date(s) to allow time to schedule the session. Any such requests received by the organization to be surveyed must be referred to the AAAHC office. The organization to be surveyed is responsible for informing the requesting individual of the date, time, and place for the presentation of information to the surveyors. The opportunity for individuals to present information in person is usually scheduled during the morning of the first survey day and normally does not exceed a total of one hour. The time and length of the session should be agreeable to all parties concerned, but final authority for such matters rests with the AAAHC survey chairperson. The Accreditation Process: The On-Site Survey Although the accreditation survey is evaluative, AAAHC emphasizes the educational and consultative benefits of the process. AAAHC uses health care professionals and administrators with health plan background and experience who continue to be active in health care settings to conduct accreditation surveys. These dedicated individuals offer their time to train and work as surveyors and use their practical knowledge in the consistent application of the Standards. The survey of a health plan is conducted by surveyors selected by AAAHC. Specific survey team members are selected, to the extent possible, on the basis of their knowledge of and experience with the range of services provided by the organization seeking accreditation. In the interest of objectivity, AAAHC cannot honor requests for specific surveyors. When arriving at an organization, the surveyor/survey team will provide identification, introduce themselves, and conduct a brief orientation conference for the organization. The surveyor or the survey chair will provide an overview of the survey agenda, and ask that the organization identify the key personnel who will provide the information and access necessary to complete the survey. This is also a time for the organization to introduce leaders and staff and to ask questions about the anticipated survey agenda and events. FEHB health plans may want to consider having their delegated entities participate in the survey either in person or by phone. Organizations are notified in advance to have specific documents and other information available in either hard copy or electronic format for surveyors during the on-site visit. This allows surveyors to review and gather information with minimal disruption to the organization s daily activities. Surveyors may, however, ask to see additional documents, may request additional information during the on-site survey, or request to meet with staff members of key delegated entities. The FEHB health plan s failure to provide information requested by AAAHC or by the surveyors may be grounds for termination of the survey or accreditation process. At the conclusion of the on-site survey, the surveyors hold a summation conference at which they present their findings to representatives of the organization for discussion and clarification. The surveyors are fact finders for AAAHC and do not render the final accreditation decision, so no opinion regarding the accreditation decision is provided during this conference. Members of the health plan s governing body and administration are encouraged to take this opportunity to comment on or rebut the findings, as well as to express their perceptions of the survey. When an organization engages a consultant to prepare for accreditation, the consultant s participation in the on-site AAAHC accreditation survey is limited to attendance at the survey opening conference and/or the summation conference. In addition, the AAAHC survey chairperson has the right to limit or exclude the participation of any individual(s) in any or all parts of the on-site accreditation survey activities. Final decision for consultant participation remains with the chair of the survey team ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 6

17 AAAHC Policies and Procedures Surveyor Conduct During a Survey Surveyors are representatives of AAAHC. Their first priority when conducting surveys is to be ambassadors of AAAHC, objective fact finders, and educators when appropriate. AAAHC surveyors do not participate in surveys of organizations that may be in direct competition with their business interests, or that bear any significant beneficial interest to the surveyor or the surveyor s immediate family. AAAHC policy also states that, while serving as representatives of AAAHC, surveyors may not solicit personal business or take part in any activities that appear to be in furtherance of their personal, entrepreneurial endeavors. In support of these policies, surveyed organizations should refrain from offering consultative or other types of business to their AAAHC surveyor(s), and/or to members of the surveyors immediate families. Please immediately report a survey team conduct concern or question to AAAHC at All information, including, but not limited to, non-public information submitted on a confidential basis by parties seeking accreditation, schedule lists for future site visits, survey report forms, reports of the internal proceedings and deliberations of AAAHC standing and ad hoc committees, interviews, statements, memoranda, and other data used in the course of business are to remain strictly confidential and will not be disclosed to any other party, except as described on page 3. Additions to the Survey Team An organization that applies for survey accepts additions to the survey team as determined by AAAHC, as follows: Observers AAAHC staff and individuals approved by AAAHC may observe a survey as part of staff development and ongoing quality improvement of the accreditation process. Observers do not participate in the on-site survey process in any manner. Additional Surveyors AAAHC reserves the right to assign additional AAAHC surveyors as part of ongoing surveyor education procedures. All surveyors may actively participate in the on-site survey process. The presence of observers or additional surveyor(s) for the purposes outlined above does not result in any additional charge to the organization, nor may it serve as grounds for any challenge to the accreditation survey decision. AAAHC Policy on the conduct of provider medical record review and audit. On site review of provider medical records during a survey occurs only when required by state regulation, or when a surveyed organization owns and operates clinics where the delivery of care to members takes place. In such instances the survey chair will determine the site and records sample based on state regulation or AAAHC procedure. of the medical record review is not included in the overall scoring of the health plan in either instance. The results of the medical record review will be provided to the organization as part of the final report but scoring of Chapter 6 will not include any of the results of the medical record review conducted by the survey team. The Accreditation Process: After the Survey AAAHC works with a third-party vendor to conduct an on-going evaluation of our accreditation process and the surveyors. A representative from a calling center will contact the FEHB health plan s designated primary contact approximately one week after the survey to discuss the recent survey experience. Obtaining this input by telephone provides AAAHC with a streamlined, efficient means of receiving feedback. An organization s feedback will have no bearing on the accreditation decision. Accreditation Decision and Notification Accreditation decisions are made by the AAAHC Accreditation Committee after careful review of the information gathered during the survey and documented in the survey report, other applicable supporting documents, and recommendations of surveyors and staff. All documents reflecting the opinions or deliberations of any AAAHC surveyor, staff member, committee member, or its officers or directors constitute peer review materials and will not be disclosed to the organization seeking accreditation or to any third party except as required by law ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 7

18 AAAHC Policies and Procedures AAAHC expects substantial compliance with the applicable Standards. Accreditation is awarded to organizations that demonstrate such compliance and adhere to AAAHC accreditation policies, except as provided by law. Compliance is assessed through at least one of the following means: 1. Documented evidence. 2. Answers to detailed questions concerning implementation. 3. On-site observations and interviews by surveyors. (Surveyors expect to have at least telephone access to representatives from delegated entities.) The overall compliance with AAAHC Standards determines if accreditation will be awarded. AAAHC carefully reviews information supplied by the organization, obtained during the survey, and any other relevant information before making an accreditation decision. A surveyor, staff member, or member of the AAAHC Board of Directors who is in any way affiliated with an organization, or whose participation represents a conflict of interest, is not allowed to participate in deliberations or voting relative to the accreditation status of that organization. The organization will be notified in writing of the accreditation decision and will receive a detailed report of the survey findings. In the event that a decision is made to deny accreditation, the organization generally has an opportunity to provide additional information before a final denial decision is rendered. When the accreditation decision is based upon findings from a survey, the decision is based on the organization s compliance with AAAHC Standards in effect at the time of the survey. In the event that a decision is made to revoke accreditation, the organization will be notified of the revocation of accreditation, including the effective date. See Denial or Revocation of Accreditation on page 9 and Appendix A, page 81. Term of Accreditation Following an accreditation survey, an organization may be awarded a three-year term of accreditation or be denied accreditation. See Denial or Revocation of Accreditation in Appendix A. Organizations may also receive a three-year term with intra-cycle activities required for continued assessment of ongoing compliance with the Standards. AAAHC awards accreditation for three years when it concludes that the organization is in substantial compliance with the Standards and AAAHC has no reservations about the organization s continuing commitment to high-quality member care and services consistent with the Standards. Please note that Standards marked with an asterisk (and listed below) must be fully met as a condition of accreditation and if not fully met, this non-compliance could serve as sufficient grounds for a non-accreditation decision. Must fully meet Standards 1. Member Rights, Responsibilities and Protections F. Members are informed about procedures for expressing suggestions, complaints, and grievances, including those procedures required by state and federal regulations. 2. Governance G. The organization, through its governing body, adopts policies and procedures to resolve grievances and external appeals, as required by state and federal law and regulations. H. The governing body meets as appropriate to the organization s needs and maintains minutes or other records that may be necessary for the orderly conduct of the business and the provision of health care services to its members. 3: Administration I. The organization has an organized and timely process for resolving members grievances that includes an expedited procedure for emergency cases, and includes provisions for identifying, analyzing, and evaluating grievances and appeals, and methods for notifying members and/or providers of the resolution of grievances and appeals ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 8

19 AAAHC Policies and Procedures Plan for Improvement (PFI) The AAAHC will request that an organization submit a Plan for Improvement (PFI) when it is determined that follow-up on some areas is required before assessment at the next reaccreditation survey. The PFI must be submitted within ten calendar days following the organization s receipt of the written request. The PFI must include, at least: Standard Identifier, survey findings, corrective actions, party responsible for implementation of corrective actions, and implementation timeline. AAAHC will notify the organization if additional information is required. If an organization fails to submit its PFI within the required time frame, accreditation may be revoked. Interim Survey An interim survey will be conducted when AAAHC determines that an on-site visit is necessary to review the organization s implementation of the PFI. The organization will be notified of the time frame for the interim survey. Following the interim survey, the organization s accreditation term may be maintained, reduced, or revoked. The organization will be assessed a fee for an Interim Survey. Denial or Revocation of Accreditation AAAHC denies accreditation to an organization when it concludes that the organization is not in substantial compliance with AAAHC Standards and/or AAAHC policies or procedures. When the accreditation decision is based upon findings from a survey, the decision is based on the organization s compliance with the Standards in effect at the time of the survey. Reasons for Denial or Revocation AAAHC reserves the right to revoke or deny the accreditation of any organization at any time without prior notice. Revocation or denial of accreditation may occur if any of the following is true. The organization: 1. No longer satisfies AAAHC Survey Eligibility Criteria. 2. Is no longer in compliance with AAAHC policies, procedures or Standards. 3. Has significantly compromised or jeopardized the well-being of members. 4. Has failed to act in good faith in providing data and other information to AAAHC. 5. Has failed to notify AAAHC within 30 calendar days of any significant change. For a list of what may constitute a significant change, see Continuation of Accreditation Following a Significant Change on page Has failed to notify AAAHC within 30 calendar days of an imposed sanction, changes in license or qualification status, governmental investigation, criminal indictment, guilty plea or verdict in a criminal proceeding (other than a traffic violation), or any violation of state or federal law with respect to the organization, its owners, or its health care professionals. 7. Has failed to allow a surveyor timely access to the organization to conduct a survey. In addition, AAAHC may revoke or reduce the organization s existing term of accreditation when it determines that there is a material change in the organizational structure, financial viability, operations, ownership or control of the organization or its ability to perform services, such that a new survey is required to determine the organization s compliance with AAAHC Survey Eligibility Criteria or the Standards. Revocation of accreditation may be retroactive to the date of the material change, the imposition of sanctions, or the violation of law. Appeal of Accreditation Decision A decision of denial or revocation of accreditation by AAAHC generally may be appealed. The appeal of any decision is governed by AAAHC appeal procedures which are in effect at the time of the appeal. Refer to Appendix A. In the unlikely event that an applicant organization, after exercising its right to appeal and upon final decision by the AAAHC Board of Directors, seeks further appeal, the applicant shall have the right to submit such decision for settlement by arbitration administered by the American Arbitration Association in Chicago, Illinois, in accordance with its Commercial Arbitration Rules. Judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. An organization that is not granted accreditation or that has its accreditation revoked may apply for another survey at any time following the decision, as long as it has not exercised its right to appeal. After receiving a denial of accreditation or having its accreditation revoked, the organization must submit a completed, signed Health Plan Application for Survey and application fee if applying for another survey ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 9

20 AAAHC Policies and Procedures Limitations on Other Rights The applicant waives all other rights to sue or to resolution of any such claims against AAAHC, its officers, directors, employees, agents, surveyors, and members of its committees in a court of law. The applicant recognizes and agrees that it shall not be entitled to monetary damages, whether compensatory, consequential, collateral, punitive, or otherwise, from AAAHC, its officers, directors, employees, agents, surveyors, and members of its committees as a result of any controversy or claim with AAAHC arising out of any procedures or decision with respect to accreditation. Public Recognition of AAAHC Accreditation AAAHC publishes the list of organizations that are currently accredited at AAAHC-accredited organizations are encouraged to publicly display the AAAHC Certificate of Accreditation except in states where such posting is regulated by law. Please note that the certificate will reflect the legal name of the organization, as well as one additional name, if appropriate (i.e., doing business as ). Representation of AAAHC accreditation to the public must accurately reflect the AAAHC-accredited entity. All certificates remain the property of AAAHC and must be returned if the organization loses its accreditation for any cause. Continuation of Accreditation Accredited organizations are required to maintain operations in compliance with the most current AAAHC Standards and policies throughout their accreditation term. AAAHC reserves the right to amend Standards and policies so long as it provides all accredited organizations with notice of such amendments, or includes such amendments in the most recent edition of the handbook. Currently-accredited organizations must complete and submit the application, supporting documentation, and application fee for their subsequent full accreditation survey (referred to as a Re-accreditation Survey). Please visit to complete the Health Plan Application for Survey and for further information. To prevent a lapse in accreditation, an organization should ensure that all documentation is submitted to AAAHC at least five months prior to its accreditation expiration date. In states where accreditation is mandated by law, an organization should submit the completed application and other required documentation a minimum of six months prior to its accreditation expiration date. Submission of an application, even if complete, fewer than 60 calendar days prior to the accreditation expiration date will result in a lapse of accreditation and an Initial Accreditation Survey will be scheduled for the organization. Continuation of Accreditation Following a Significant Change Accredited organizations must notify AAAHC in writing within 30 calendar days of any significant organizational, operational, or financial changes including, but not limited to: Mergers. Change in controlling interest/ownership. Consolidation. Name change. Organization relocation to another physical location. Additional services. Expansion to new service area. Any interruption in delivery of health care service that exceeds 30 calendar days. Adverse publicity or adverse media coverage related to the organization or its providers. Changes in state license or other applicable license, (e.g., business license), federal certification, or qualifying status. Bankruptcy or other significant change in the financial viability of the organization. Any governmental investigation, including local, state, or federal authorities involving, directly or indirectly, the organization or any of its officers, administrators, or other staff, in their role within the organization. Criminal indictment, guilty plea or verdict in a criminal proceeding (other than a traffic violation) involving, directly or indirectly, the organization or any of its officers, administrators, or other staff in their role within the organization. An organization s duty to provide this information continues throughout the entire accreditation process and term. In the event that the organization is exercising its right to appeal, the organization must notify AAAHC in writing immediately of any such changes. Failure to notify AAAHC in writing may result in an immediate revocation of accreditation or termination of the right to appeal ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 10

21 AAAHC Policies and Procedures Accreditation is not automatically maintained when an accredited organization undergoes significant changes as described above. AAAHC will determine whether the current accreditation term will be maintained and establish any such conditions. End of Accreditation When a health plan s accreditation term has expired and the organization is not seeking re-accreditation, or it is choosing to withdraw from accreditation prior to the end of its accreditation term, AAAHC requires: Return of all AAAHC Certificates of Accreditation to AAAHC, Attn: Accreditation Services, 5250 Old Orchard Road, Suite 200, Skokie, IL Review of internal information, e.g., letterhead, fax forms, and internal recorded phone messages, to ensure that the AAAHC name and/or logo have been removed. Review of marketing materials, website, radio or television ads, telephone directory advertisements, and all other materials to ensure the removal of or reference to the AAAHC name, logo, and accreditation status. Compliance with Omnibus Reconciliation Act of 1980 For any health care organization that pays AAAHC $10,000 or more in any 12-month period to comply with Section 952, PL , the Omnibus Reconciliation Act of 1980, AAAHC hereby stipulates that only those AAAHC records, contracts, documents, or books that are necessary to verify the extent and nature of AAAHC costs will be available for four years after the survey, consultation or contracted services are completed to the Secretary of the Department of Health and Human Services (DHHS), the Comptroller General of the United States, or any of their duly authorized representatives. This stipulation is provided as a matter of policy by AAAHC in lieu of providing separate contracts for each affected organization. These same conditions will apply to any subcontracts AAAHC has with related organizations if such payments amount to $10,000 or more in any 12-month period. This policy applies to all contracts, surveys, and AAAHC records as of December 5, 1980, and so long as these regulations remain in force ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 11

22 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 12

23 Standards

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25 01: Member Rights, Responsibilities and Protections An accreditable organization recognizes the basic human rights of members. Such an organization has the following characteristics: A. Members are treated with respect, consideration, and dignity and are afforded appropriate privacy. 1. The health plan has a written policy on member rights and responsibilities. 2. The health plan or its delegated entities distribute the policy on member rights and responsibilities to its members. 3. The health plan or its delegated entities distribute the policy on member rights and responsibilities to network providers. 4. Compliance is evaluated and verified during network provider site visits, or through the oversight audit of its delegated entities conducted at least annually. 5. When problems or concerns are identified by the FEHB plan or its delegated entities, there is evidence of a process for the implementation of interventions validated through the health plan s annual oversight audit of the delegated entities. Fully Substantially Partially Minimally Non- 4 of 5 elements are 3 or 4 of 5 elements are 2 of 5 elements are 1 or no element is B. Member disclosures and records are treated confidentially, and members are given the opportunity to approve or refuse their release, except when release is required by law. 1. The health plan has a written (HIPAA- and Omnibus-compliant) policy regarding the release of personal health information of members and maintains appropriate business associate agreements. 2. The health plan or its delegated entities distribute the policy to network providers and network provider staff. 3. Compliance is evaluated and verified during network provider site visits, or through the oversight audit of its delegated entities conducted at least annually. 4. There is evidence of a process for the implementation of interventions when problems and concerns are identified, or through the oversight audit of its delegated entities conducted at least annually ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 13

26 01: Member Rights, Responsibilities and Protections Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is C. Members (or a patient designated person or legally authorized person) are provided information about their health care and are provided the opportunity to participate in decisions related to their health care. 1. The health plan has written policies addressing provider responsibility to provide members, or their designated person or legally authorized individual, with complete information concerning their diagnosis, evaluation, treatment, and prognosis. 2. The health plan has written policies addressing provider responsibility to give members the opportunity to participate in decisions involving their health care, except when such participation is contraindicated for medical reasons. This requirement may be delegated as outlined in delegate agreements. 3. Evidence that members have been informed of the policies outlined in guidelines 1 and 2 above is present (e.g., member handbook, provider manual, provider contracts, website, etc.). Compliance is monitored through delegate audits conducted at least annually, if this is delegated. 4. Evidence is present that network providers have been informed of the policies outlined in guidelines 1 and 2 above (e.g., member handbook, provider manual, provider contracts, website, etc.). Compliance is monitored through delegate audits conducted at least annually, if this is delegated. 5. Evidence of compliance is present in medical records (e.g., informed consents, progress notes, etc.). Compliance is monitored through delegate audits conducted at least annually, if this is delegated. 6. There is evidence of a process for the implementation of interventions to correct identified deficiencies, or monitored through the oversight audit of its delegated entities conducted at least annually, if this is delegated. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 14

27 01: Member Rights, Responsibilities and Protections D. The organization establishes member rights and responsibilities and makes information available to members and network provider staff regarding services, fees, and other issues. Documentation exists with the health plan or its delegated entities for: 1. Member rights including those specified in A, B, and C above. 2. Member conduct, responsibilities and participation. 3. Services available at the organization for members. 4. Provisions for after-hours and emergency care. 5. Fees for services. 6. Payment policies. 7. Members right to refuse to participate in research. 8. Advance directives, as required by state or federal law and regulations. 9. Credentials of health care professionals. Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 4, 5 or 6 of 9 elements are 3 of 9 elements are 2 or fewer elements are E. Prior to receiving care, members are informed of their responsibilities. These responsibilities require the member to provide certain information and comply with certain requirements and the health plan to comply with certain requirements. 1. The health plan or its delegated entities establish a member responsibilities document that covers at least the following requirements: a. Members must provide complete and accurate information to the best of their ability about their health, medications (including over-the-counter products and dietary supplements), and any allergies or sensitivities. b. Members agree to follow the treatment plan prescribed by their provider and to participate in their care. c. Members must inform the provider about any living will, medical power of attorney, or other directive that could affect their care. d. Members accept personal financial responsibility for any charges not covered by insurance, if applicable. e. Members must treat all health care providers, staff, and others respectfully. 2. Written member rights, responsibilities, and protections are included in the member handbook and provider manual. 3. Members are informed through the Evidence of Coverage, member handbook, newsletters, and/or the health plan s website, of their right to change their primary care network provider if other qualified network providers are available ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 15

28 01: Member Rights, Responsibilities and Protections (continued) 4. The health plan or its delegated entities have methodology in place to expedite action on requests to change a provider. 5. The health plan or its delegated entities make information regarding malpractice insurance of providers available upon request. 6. If applicable, providers who lack malpractice insurance coverage have posted such information in a prominent location in their office/s (verified through provider site visits or by the delegated entities and verified through the delegate audits conducted at least annually). 7. Items in 1-6 above that are delegated are monitored by the health plan through the delegate audits conducted at least annually, and interventions for non-compliance are implemented. Fully Substantially Partially Minimally Non- 5 or 6 of 7 elements are 3 or 4 of 7 elements are 2 of 7 elements are 1 or no element is F.* Members are informed about procedures for expressing suggestions, complaints, and grievances, including those procedures required by state and federal regulations. The member handbook and/or Evidence of Coverage contains information about how to communicate suggestions, complaints, and grievances, including those procedures required by state and federal regulations. The health plan must be able to demonstrate the complaint and grievance procedure for its members if this function is delegated. Fully Substantially Partially Minimally Non- Element is No scoring option. Element is not * This Standard must be fully met as a condition of accreditation. If not fully met, this non-compliance could serve as sufficient grounds for a non-accreditation decision ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 16

29 02: Governance An accreditable organization has a governing body that sets policy, is responsible for the organization, and is administered in a manner that ensures the provision of high quality health care services, and that fulfills the organization s mission, goals, and objectives. Such an organization has the following characteristics: A. The organization is a legally constituted entity. 1. Evidence exists that the organization is a legally constituted entity. 2. The names and address of all owners and/or controlling parties is disclosed. Fully Substantially Partially Minimally Non- Both elements of the No scoring option. 1 of 2 elements is No scoring option. Neither element is B. The governing body addresses and is fully and legally responsible, either directly or by appropriate delegation, for the operation and performance of the health plan. The governing body, either directly or by appropriate delegation: 1. Determines the mission, goals, and objectives of the organization. 2. Establishes an organizational and reporting structure. 3. Ensures that the health plan personnel are adequate and appropriately trained to carry out the mission and establishes job titles and position descriptions that identify roles, accountabilities, responsibilities, and reporting relationships for all officers, administrators and staff. 4. Establishes policies and procedures necessary for the orderly conduct of the organization, addressing the organization s obligation and responsibilities to its members and designed to ensure that its obligations to members and those with whom it contracts are met. 5. Establishes a policy on the rights, responsibilities and protection of its members. 6. Establishes a system of financial management and accountability appropriate to the organization demonstrated by timely reporting of annual financial statements, financial reports, and other such required documents. 7. Formulates and documents in writing long-range plans in accordance with its mission, goals, and objectives. 8. Ensures it operates without violating federal or state anti-discrimination laws. 9. Establishes a comprehensive policy on continuing education for personnel and members ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 17

30 02: Governance Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 4, 5 or 6 of 9 elements are 3 of 9 elements are 2 or fewer elements are C. The organization, through its governing body, ensures the provision and the evaluation of quality of care for members, reducing risk through quality improvement (QI) and risk management programs and systems. 1. The governing body establishes a QI program appropriate for the organization. The health plan may delegate some components of the QI activities. 2. The health plan, through its governing body, ensures links between quality improvement and management and functions within the organization, its provider network, and any delegated entities, as applicable. 3. The health plan, through its governing body, establishes a risk management program consistent with state and applicable federal requirements and as outlined in Chapter 8.II. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is D. The organization, through its governing body, sets up delegation of activities or services to other entities that ensure the provision of necessary medical and behavioral health care services. Note: If no delegation established, this Standard is not applicable. 1. The health plan establishes contracts with all delegated entities and ensures compliance with the contracts. 2. The health plan has a detailed monitoring process in place that includes an oversight audit of the delegate entities both prior to contracting and at least annually thereafter. Fully Substantially Partially Minimally Non- Both elements of the No scoring option. 1 of 2 elements is No scoring option. Neither element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 18

31 02: Governance E. The organization, through its governing body, establishes a mechanism to fulfill all applicable obligations under local, state, and federal laws and regulations including contractual obligations of the health plan (e.g., Medicaid or Medicare). The health plan s governing body reviews and approves mechanisms to ensure compliance with: 1. Americans with Disabilities Act. 2. Medical privacy, including contractual and sub-contractual relationships. 3. Anti-fraud and abuse regulations. 4. Reporting to the NPDB. 5. HIPAA regulations. 6. OSHA rules and regulations, as appropriate. 7. State- or federally-mandated benefits. 8. Office of Personnel Management (OPM) approval processes for marketing/advertising material as applicable. Fully Substantially Partially Minimally Non- 7 of 8 elements are 5 or 6 of 8 elements are 3 or 4 of 8 elements are 2 or fewer elements are F. The organization, through its governing body, ensures the ongoing assessment of member and network provider satisfaction by conducting satisfaction surveys on a regular basis. 1. The health plan or its delegated entities ensure that member satisfaction surveys are conducted at least annually. 2. The health plan or its delegated entities ensure that network provider satisfaction surveys are conducted at least annually. 3. Evidence exists that member satisfaction survey results are analyzed on a periodic basis. This may be demonstrated through delegate oversight audits conducted at least annually. 4. Evidence exists that network provider satisfaction survey results are analyzed on a periodic basis. This may be demonstrated through delegate oversight audits conducted at least annually. 5. Evidence exists that results and analysis of satisfaction surveys by the governing body are distributed to providers and members periodically. This may be demonstrated through delegate oversight audits conducted at least annually. Fully Substantially Partially Minimally Non- 4 of 5 elements are 3 of 5 elements are 2 of 5 elements are 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 19

32 02: Governance G.* The organization, through its governing body, adopts policies and procedures to resolve grievances and external appeals, as required by state and federal law and regulations. 1. There is evidence of policies and procedures for the resolution of member complaints, grievances, and appeals that include procedures for expedited and external appeals that are compliant with state and federal laws and regulations. 2. Policies include definitions, mechanisms for how the grievances and appeals are handled and triaged, and timeframes for addressing: a. Grievances. b. Expedited or urgent grievances. c. Appeals of grievance. d. Expedited or urgent appeals of grievance. e. External appeals. 3. How the member is notified of the outcome of the grievance and/or appeal. 4. Language services that are made available to members as needed. 5. The health plan must demonstrate that it has adopted such a policy and has monitoring processes in place if the investigation and follow-up for complaints and grievances is conducted by the delegated entity. Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 5 or 6 of 9 elements are 3 or 4 of 9 elements are 2 or fewer elements are H.* The governing body meets as appropriate to the organization s needs and maintains minutes or other records that may be necessary for the orderly conduct of the business and the provision of health care services to its members. The health plan s governing body meets as appropriate to its needs, and minutes or other such records include, at least: 1. Review of members rights, responsibilities, and protection. 2. Review of delegated services. 3. Review of the quality improvement and management program activities. 4. Review of a risk management program activities. 5. Adoption and on-going review of organizational policies and procedures. 6. Review of provider network credentialing and network adequacy evaluation processes. 7. Development of provider contracts that ensure member safety and access to care. * This Standard must be fully met as a condition of accreditation. If not fully met, this non-compliance could serve as sufficient grounds for a non-accreditation decision ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 20

33 02: Governance (continued) 8. Evaluation of health education and wellness promotion activities. 9. Evaluation of case management and utilization management programs and activities. Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 4, 5 or 6 of 9 elements are 3 of 9 elements are 2 or fewer elements are I. Accredited organizations must notify AAAHC in writing, within 30 calendar days, of significant organizational, ownership, operational changes such as increase in membership or lines of business and financial status that include change in reporting status with the NAIC or state insurance regulatory entities, or quality of care events, including criminal indictment, guilty plea, or verdict in a criminal proceeding (other than a traffic violation) that directly or indirectly involve the organization or any of its officers, administrators, physicians, health care professionals, or staff within their role in the organization. Any such change/event that negatively affects the public s perception of the accredited organization or AAAHC, as the accrediting body, must also be reported. An organization s duty to provide this information continues throughout the entire accreditation term. Additionally, the organization ensures appropriate representation of accreditation status. 1. The health plan s governing body provides AAAHC with documentation of ownership changes. 2. The health plan s governing body provides AAAHC with names of new officers, directors, or owners. 3. The health plan s governing body ensures notification of AAAHC in writing of any significant changes in the organization as stipulated above within 30 days of the change(s). 4. The health plan s governing body ensures accurate representation of the health plan s accreditation status to the public. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 21

34 03: Administration An accreditable organization is administered so as to ensure the provision of high-quality health services and fulfillment of the organization s mission, goals, and objectives. A. Administrative policies, procedures, and controls are established and implemented to ensure the orderly and efficient management of the organization. 1. The health plan has established, implemented, and ensures enforcement of administrative policies, procedures, and controls for the orderly and efficient management of the organization. 2. The health plan employs qualified management personnel to carry out mission and tasks. 3. The health plan demonstrates compliance with applicable laws and regulations, and state/ federal reporting requirements. 4. The health plan has processes and programs in place to protect its assets. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is B. The organization establishes and implements fiscal controls that ensure solvency of the organization. 1. The health plan has authorization and recording procedures that are adequate to provide accounting controls over assets, liabilities, revenues, and expenses. 2. The health plan has policies and procedures for controlling accounts receivable, accounts payable, and the receipt of premium payments. 3. The health plan has established rates and charges for services it provides. 4. The health plan has established protocols for handling non-payment of premiums by members, including notification to members, and potential termination. This process may be coordinated with the health plan s delegated entities, as appropriate. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 22

35 03: Administration C. The organization demonstrates methods of communicating and reporting and has established lines of authority, accountability, and supervision in place. 1. The health plan has implemented methods of communicating and reporting designed to ensure the orderly flow of information within the plan itself and its delegated entities. 2. The health plan demonstrates a means of communication and reporting to the members. This may include processes established through the contacts/agreements with delegated entities. 3. The health plan demonstrates a means of communication and reporting to the provider network. This may include processes established through the contracts/ agreements with delegated entities. 4. The health plan has established lines of authority and accountability and demonstrates supervision of personnel and its delegated entities. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is D. The organization has controls relating to the custody of the official documents of the organization, ensures the confidentiality, security, and physical safety of data on members, providers, and staff, and has processes that ensure the appropriate handling of inquiries from governmental agencies, accrediting bodies, attorneys, consumer advocate groups, reporters, and the media, avoiding antitrust and restraint of trade issues. 1. The health plan has written policies and procedures that establish controls relating to the custody of its official documents. 2. The health plan has written policies and procedures that describe the process for maintaining the confidentiality, security, and physical safety of data on members, providers, and staff, and adherence to HIPAA and other state and federal requirements. These requirements are detailed in the contracts/agreements with its delegated entities. 3. The health plan demonstrates the ability to identify and review relationships with competing health care organizations so as to avoid antitrust and restraint of trade concerns and evaluates its delegated entities regarding such concerns at least annually. 4. The health plan documents the process for responding to inquiries from governmental agencies, accrediting bodies, attorneys, consumer advocate groups, reporters, and the media. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 23

36 03: Administration E. The organization maintains a health information system that collects, integrates, analyzes, and reports data as necessary to meet the needs of the organization. 1. The health plan s health information system collects, integrates, analyzes, and reports data as necessary to meet the needs of the organization. 2. The health information data system demonstrates, at a minimum: a. Meeting performance improvement/indicators study needs. b. Maintenance of appropriate data on health care professionals and services provided to members. c. Ensuring accurate, timely, and complete data. d. Maintenance of collected data in a standardized format to the extent feasible and appropriate. e. Having adequate support to maintain member data that permits monitoring of member utilization of resources and supports the QI activities of the organization or other departments and activities as needed. Note: Coordination of these system functions can be assessed through delegate oversight audits conducted at least annually. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is F. Human resource policies and processes are established and implemented to facilitate attainment of the mission, goals, and objectives of the organization 1. The health plan defines and delineates functional responsibilities and authority through job descriptions and ensures confidentiality training as applicable. 2. The health plan demonstrates that it employs personnel with qualifications commensurate with job responsibilities and authority, including applicable licensure or certification, verifies previous employment, and/or conducts background checks. 3. The health plan maintains personnel files that reflect the requirement for documentation of initial orientation and ongoing training according to position description as follows: a. Initial orientation within 30 days of beginning employment. b. Annual training thereafter and when there is an identified need. 4. The health plan requires periodic appraisal of each person s job performance, including current competence. 5. The health plan, through its personnel handbook and/or policies and procedures, describes incentives and rewards (if any exist) and how employee compensation is reviewed. 6. The heath plan, through its personnel handbook and/or policies and procedures, specifies responsibilities and privileges of employment, including compliance with an adverse incident reporting system, as described in Chapter 8.II: Risk Management ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 24

37 03: Administration (continued) 7. The health plan demonstrates that the personnel handbook is provided to employees at the time of employment. 8. The health plan demonstrates compliance with federal and state laws and regulations regarding the verification and eligibility for employment (I-9s and E-verification, as appropriate). Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 4, 5 or 6 of 9 elements are 3 of 9 elements are 2 or fewer elements are G. The organization periodically assesses network provider satisfaction with services provided by the organization including the utilization management processes. 1. The health plan or its delegated entities demonstrate periodic assessment of network provider satisfaction with services, including utilization management, through a survey. 2. The health plan or its delegated entities demonstrate implementation of appropriate interventions when issues are identified. 3. The health plan or its delegated entities communicate the results of such a survey to the provider network through such means as newsletters and/or via the website of the health plan or delegated entities. 4. The health plan demonstrates reporting of the survey results and any interventions initiated by the plan or its delegated entities to its governing body. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is H. The organization has procedures in place to periodically assess member satisfaction, to include network adequacy satisfaction, with the organization s services and provide feedback to both the members and the provider network ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 25

38 03: Administration 1. The health plan or its delegated entities conduct a member satisfaction survey, including assessment of satisfaction with network adequacy, at least annually, for all lines of business using such tools as CAHPS or other, similar surveys. 2. The health plan or its delegated entities analyze member satisfaction survey data. 3. The health plan collects and analyzes member complaint data, which includes member complaints, grievances and appeals, on an on-going basis. This data may come from a delegated entity. 4. The health plan or its delegated entities have a member satisfaction survey tool that addresses at least the following: a. Satisfaction with the provider network. b. Satisfaction with the FEHB health plan s and delegated entity s services, i.e., customer service, claims processing and payment, scope of benefits, and referral procedures. c. Satisfaction with provider availability. d. Satisfaction with member access to health care services. 5. The health plan or its delegated entities intervene to improve the level of member satisfaction. 6. The health plan ensures that member satisfaction and complaint information are components of its quality improvement program. 7. The health plan or its delegated entities distribute member satisfaction information to the members and provider network. 8. The health plan distributes member satisfaction information to the governing body QI committee, and other relevant committees and staff throughout the organization. Fully Substantially Partially Minimally Non- 9 or 10 of 11 elements are 7 or 8 of 11 elements are 4, 5 or 6 of 11 elements are 3 or fewer elements are I.* The organization has an organized and timely process for resolving members grievances that includes an expedited procedure for emergency cases and includes provisions for identifying, analyzing, and evaluating grievances and appeals, and methods for notifying members and/or providers of the resolution of grievances and appeals. 1. The health plan has a policy for resolving members grievances that includes an expedited procedure for emergency situations and appeal rights. This policy is communicated as a contract requirement to the delegate entities as appropriate. 2. The health plan or its delegated entities ensure that individuals reviewing a grievance involving an adverse determination have appropriate expertise. Individuals with the appropriate clinical expertise review grievances of a clinical nature. * This Standard must be fully met as a condition of accreditation. If not fully met, this non-compliance could serve as sufficient grounds for a non-accreditation decision ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 26

39 03: Administration (continued) 3. The health plan or its delegated entities make review procedures available to the member and/or providers acting on behalf of a member through such documents as the member handbook, subscriber agreement, provider manual and/or the website. 4. The health plan or its delegated entities issue a copy of the written decision to the member and to any provider who submits a grievance on behalf of a member. 5. The health plan or its delegated entities establishes written procedures for an expedited review of an urgent grievance. The expedited reviews are evaluated by appropriate clinical peers or peers who have not been involved in the initial adverse determination. 6. The health plan or its delegated entities, ensures notification of the member (or provider acting on behalf of the member) as expeditiously as the member s medical condition required in expedited reviews. 7. The health plan or its delegated entities, provides a system for reporting, collection, and analysis of member appeals and grievances. 8. The health plan ensures that when the grievance and appeal process is completed, any corrective actions are noted and the situation is reviewed again by the grievance coordinator. Fully Substantially Partially Minimally Non- 7 of 8 elements are 5 or 6 of 8 elements are 3 or 4 of 8 elements are 2 or fewer elements are J. The organization has established policies and procedures in place related to referrals, behavioral health, emergency care, second opinions, and out-of-network care that are made known to the membership and the provider network. 1. The health plan or its delegated entities provide information to members during initial enrollment, and annually thereafter, and to their website concerning: a. A policy regarding specialty referrals, including to behavioral health providers. b. When to seek direct access to emergency care or utilize 911 services, including for behavioral health. c. Policies regarding services obtained outside the health plan s or delegated entities network and the procedure(s) for obtaining them, including second opinions. d. Policies on member charges, if any. e. Procedures for member notification of benefit changes and/or termination of benefits, services, or service delivery. f. Procedures for appealing decisions regarding coverage, benefits, or services, as required by applicable state or federal law and regulations. 2. The health plan or its delegated entities distribute the information as described above to its provider network through such documents as the provider manual and/or website ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 27

40 03: Administration Fully Substantially Partially Minimally Non- 5 or 6 of 7 elements are 3 or 4 of 7 elements are 2 of 7 elements are 1 or no element is K. The organization is accountable for the oversight of any functions or services that are delegated* to another entity. 1. The health plan ensures that the written delegation agreement outlines at least all of the following: a. Delegated entities services, along with AAAHC Standard requirements. b. Responsibilities of the organization and the delegated entity. c. Reporting responsibilities. d. Evaluation process for review and ongoing monitoring of performance, including performance goals. e. Remedies for substandard performance. f. A system of due process for terminating the agreement if performance is inadequate. g. How PHI is maintained in a confidential manner. h. Details on applicable policies and procedures such as Grievances and Appeals, and referrals. 2. The health plan ensures that an audit to evaluate the services of the delegated entity is performed prior to initiating the delegation. 3. The health plan conducts periodic assessments to ensure the delegated entity has the capacity to perform the required delegated services defined in the sub-contractual relationship before executing an agreement. 4. The health plan ensures that it retains the right to approve, suspend, or terminate the individual provider s or provider s group participation in the network in conjunction with the delegate, as appropriate. 5. The health plan ensures that an annual or more frequent review is conducted of the delegated entity and the relevant agreements to ensure that services have been provided in accordance with the terms. Such oversight may need to be conducted as frequently as weekly or monthly depending on the specific delegated function. 6. The health plan ensures implementation of corrective measures for the delegated entities when necessary. 1 Delegation is defined as a formal process by which an organization gives another organization the authority to perform certain administrative functions on its behalf, such as credentialing, utilization management, and quality improvement. Although an organization can delegate the authority to perform a function, it cannot delegate the responsibility for ensuring that the function is performed appropriately and in compliance with AAAHC Standards. The organization fulfills its responsibility and exercises its authority by providing oversight of the delegate ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 28

41 03: Administration Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is L. The organization maintains a compliance program consistent with state and federal requirements. 1. The health plan has adopted a compliance program consistent with state and federal requirements. 2. The compliance program has been approved by the health plan s governing body. 3. The health plan s governing body has designated a person responsible for the compliance program. 4. The health plan has a monitoring process to ensure on-going adherence to the compliance program. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 29

42 04: Provider Network Credentialing This chapter describes the requirements for credentialing network health care professionals to provide member care in an accreditable organization. Credentialing is a three-phase process of assessing and validating the qualifications of an individual to provide services. The objective of credentialing is to establish that the applicant has the specialized professional background that he or she claims and that the position requires. An accreditable organization: (1) establishes minimum training, experience, and other requirements (i.e., credentials) for physicians and other health care professionals; (2) establishes a process to review, assess, and validate an individual s qualifications, including education, training, experience, certification, licensure, and any other competenceenhancing activities against the organization s established minimum requirements; and (3) carries out the review, assessment, and validation as outlined in the organization s description of the process. A. The provider network must be accountable to the governing body. The governing body establishes and is responsible for a credentialing and re-credentialing process, applying criteria in a uniform manner to appoint individuals to provide patient care for the organization. The governing body approves mechanisms for credentialing, re-credentialing, the granting of core privileges, and suspending or terminating privileges, including provisions for appeal of such decisions. The governing body may determine that this function will be accomplished directly or through delegation. 1. The governing body establishes policies and procedures for the credentialing and re-credentialing of network providers that outlines specific criteria and their application, and timelines to appoint individuals to provide patient care for the organization in an expeditious manner. This may be coordinated with the delegate entities. 2. The governing body approves credentialing, re-credentialing, the granting of core privileges, and suspending or terminating privileges, including provisions for appeal of such decisions. This function may be accomplished through delegation agreements. 3. The governing body makes, either directly or through delegation agreements, initial credentialing, re-credentialing, and assignment or curtailment of credentialing based on professional evaluation. 4 The health plan must demonstrate an oversight process of the delegated entities when credentialing of the provider network is delegated with monitoring at least annually. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 30

43 04: Provider Network Credentialing B. On an application for initial credentialing, the applicant is required to provide sufficient evidence of training, experience, and current documented competence in performance of the procedures for which core privileges are requested. There is minimum credentialing information that shall be provided for evaluation of the candidate. The health plan or its delegated entities ensure that individual provider initial applications and documentation include: 1. A history of education, training, and experiences that is verified, using an AAAHC-acceptable source. 2. Current state license with verification through the state licensing board website. 3. DEA registration (if applicable) with verification through the DEA website. 4. Medical liability coverage information. 5. NPDB query. Note: The NPDB Continuous Query is an acceptable service for meeting the requirement for querying the NPDB. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is C. The organization shall require and review other relevant information at the initial application which includes a signed statement releasing the organization from liability and attesting to specific information and to the correctness and completeness of the submitted information. The signed release and attestation statement, which may be obtained through delegated entities, includes: 1. Professional liability claims history. 2. Information on licensure revocation, suspension, voluntary relinquishment, licensure probationary status, or other licensure conditions or limitations. 3. Complaints or adverse action reports filed against the applicant with a local, state, or national professional society or licensure board. 4. Refusal or cancellation of professional liability coverage. 5. Denial, suspension, limitation, termination, or nonrenewal of professional privileges at any hospital, health plan, medical group, or other health care entity. 6. DEA and state license action. 7. Disclosure of any Medicare/Medicaid sanctions. 8. Conviction of a criminal offense (other than minor traffic violations) ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 31

44 04: Provider Network Credentialing (continued) 9. Current physical, mental health, or chemical dependency issues that would interfere with an applicant s ability to provide high-quality patient care and professional services. 10. Attestation to the correctness and completion of the information and release of the organization from liability. Fully Substantially Partially Minimally Non- 8 or 9 of 10 elements are 5, 6 or 7 of 10 elements are 3 or 4 of 10 elements are 2 or fewer elements are D. Upon completion of the application, the credentials are verified according to policies and procedures established by the organization. The organization may use information provided by a Credentials Verification Organization (CVO) after proper assessment of the capability and quality of the CVO. Alternatively, a CVO may demonstrate such capability and quality by becoming accredited or certified by a nationally recognized accreditation organization. 1. The health plan establishes policies and procedures for verifying credentials in accordance with AAAHC Standards using AAAHC-accepted primary or secondary source verification and conducting queries. These policies and procedures are outlined in the delegation agreements and are monitored by the plan at least annually. 2. The health plan or its delegated entities demonstrate that established policies and procedures are followed. 3. The health plan or its delegated entities demonstrate that it conducts primary or secondary source verification In accordance with AAAHC Standards and using AAAHC-accepted sites for primary or secondary verification. This verification process may be accomplished through delegation with monitoring oversight conducted by the plan at least annually. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is E. Network providers must apply for re-credentialing every three years, or more frequently if state law or organizational policies so stipulate. At reappointment, the organization requires completion of a reappointment application and verifications and queries ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 32

45 04: Provider Network Credentialing 1. The health plan has established policies and procedures for re-credentialing providers. These policies are incorporated into delegation agreements, if pertinent. 2. The health plan or its delegated entities demonstrate adherence to established policies and procedures. 3. The health plan or its delegated entities re-credential providers a minimum of every three years or more frequently if state law or organizational policies require. 4. The health plan or its delegated entities conduct verification and queries using AAAHC accepted sources at re-credentialing of at least: a. Current state licensure. b. Current DEA certification. c. Current malpractice insurance, if applicable. d. Board certification, if applicable. e. NPDB query. 5. The health plan or its delegated entities ensure the completion of an attestation from the provider that contains all of the following: a. Information on licensure revocation, suspension, voluntary relinquishment, licensure probationary status, or other licensure conditions or limitations. b. DEA or state licensure action. c. Professional liability claims history. d. Refusal or cancellation of professional liability coverage. e. Complaints or adverse action reports filed against the applicant with a local, state, or national professional society or licensure board. f. Denial, suspension, limitation, termination, or non-renewal of professional privileges or membership at any clinic, hospital, health plan, or other institution. g. Disclosure of any Medicare/Medicaid sanctions. h. Conviction of a criminal offense (other than minor traffic violations). i. Current physical, mental health, or chemical dependency issues that would interfere with an applicant s ability to provide high quality patient care and professional services. 6. The re-credentialing application includes a signed and dated statement releasing the plan, and its delegated entities, if pertinent, from liability and attesting to the correctness and completeness of the submitted information. 7. Provider-specific performance data, such as member satisfaction, member complaints, and peer review activity are used as part of the re-credentialing process. If this is performed through a delegation agreement, the plan monitors adherence at least annually through oversight monitoring. Fully Substantially Partially Minimally Non- 5 or 6 of 7 elements are 3 or 4 of 7 elements are 2 of 7 elements are 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 33

46 04: Provider Network Credentialing F. The organization shall monitor and document current licensure, professional liability insurance (if required), certifications, and DEA registration, where applicable, on an ongoing basis. The health plan or its delegated entities ensure ongoing monitoring with documentation and verification of: 1. Licensure and state sanction activities. 2. Professional liability insurance. 3. Medicare and Medicaid sanctions. 4. Board certifications, as applicable. 5. DEA registration. Fully Substantially Partially Minimally Non- 4 of 5 elements are 3 or 4 of 5 elements are 2 of 5 elements are 1 or no element is G. Core privileges (e.g. primary care and/or specific areas/specialties) are granted by the organization to the health care professional. 1. The health plan has policies and procedures related to the granting of core privileges for primary care, specialty, and other providers. These policies and procedures are outlined in the delegation agreements, if pertinent. 2. The health plan or its delegated entities grant core privileges (by specialty) based on the applicant s qualifications. 3. The health plan or its delegated entities grant core privileges (by specialty) for a specified period of time. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 34

47 04: Provider Network Credentialing H. Mechanisms are in place for the organization to notify licensing and/or disciplinary bodies or other appropriate authorities, including the NPDB, when a network provider s privileges are suspended or terminated, as required by state or federal law and regulations. 1. The health plan has policies and procedures that define the process used to notify licensing and/or disciplinary bodies and/or other appropriate authorities when an individual network provider has received a disciplinary action by the governing body. These policies and procedures are included in the delegation agreements, if pertinent. 2. The health plan has policies and procedures that define the process for notifying the NPDB when an individual network provider has received a disciplinary action by the governing body. These policies and procedures are included in the delegation agreements, if pertinent. Fully Substantially Partially Minimally Non- No scoring option. 1 of 2 elements is No scoring option. Neither element is I. The organization has its own independent process of credentialing. The approval of credentials or the granting of core privileges requires review and approval by the organization s governing body. Credentials may not be approved, nor core privileges granted, solely on the basis that another organization, such as a hospital, approved credentials or granted core privileges, without further review. Such status at another organization may be included in the governing body s consideration of the application. The health plan has an independent credentialing process. This process may be accomplished through delegation agreements. Fully Substantially Partially Minimally Non- Element is No scoring option. Element is not J. The organization has a credentialing process for confirming that contracted provider organizations, such as surgery centers, hospitals, home health agencies, nursing homes, behavioral health providers, and pathology and medical laboratories, have been either reviewed and approved by a recognized accrediting body or comply with developed and implemented standards of participation, if the provider organization has not been approved by a recognized accrediting body ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 35

48 04: Provider Network Credentialing 1. The health plan or its delegated entities confirm that contracted provider organizations, such as surgery centers, hospitals, home health agencies, nursing homes, behavioral health providers, pathology and medical laboratories, either have been reviewed and approved by a recognized accrediting body or have a quality improvement program in effect that ensures delivery of quality care. 2. The health plan develops and implements standards of participation, including confidentiality statements, if a recognized accrediting body has not approved the provider organization. These standards of participation are outlined in the delegation agreements, if relevant. 3. The health plan or its delegated entities ensure that the contracted provider organization is appropriately licensed by the state, if applicable. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is K. Network providers practice their professions in an ethical and legal manner. 1. Grievance and appeals review demonstrates ethical behavior and appropriate response to member concerns. 2. Review of medical liability cases does not reveal unethical behavior. Fully Substantially Partially Minimally Non- No scoring option. 1 of 2 elements is No scoring option. Neither element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 36

49 04: Provider Network Credentialing L. The organization facilitates the provision of high-quality health care, as demonstrated by documentation that health care provided is consistent with current professional knowledge. 1. The health plan or its delegated entities periodically review clinical records to ensure that documentation demonstrates that care provided is consistent with current professional knowledge and incorporates these findings into the re-credentialing process. If medical records are not available for review by either the FEHB health plan or its delegated entities, a plan of how assessment of this requirement is accomplished is outlined. 2. The health plan or its delegated entities periodically review clinical records to monitor compliance with clinical practice guidelines and incorporates these findings into the re-credentialing process. If medical records are not available for review by either the FEHB health plan or its delegated entities, a plan of how assessment of these requirements is accomplished is outlined. 3. The health plan or its delegated entities demonstrate on-going monitoring of overall network provider performance that is used as a part of the process for continuation of credentialing. 4. The health plan or its delegated entities conduct improvement initiatives when issues are identified in the review of the clinical records. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 37

50 05: Network Adequacy An accreditable organization ensures a healthcare delivery network with sufficient numbers and types of healthcare providers and facilities appropriate to its membership. The healthcare needs of the membership related to covered services are monitored to ensure their adequacy, accessibility, and quality. Such an organization has the following characteristics: A. The organization has a process in place to ensure a network of primary care and specialty providers that meet the needs of the population served, including access to care standards for medical and behavioral health, and has policies and procedures to communicate such information to the membership and provider network. 1. The health plan has identified geographic access standards for primary and specialty care providers to meet the needs of its membership and includes this in its delegation agreements, if pertinent. 2. The health plan defines access to care standards for medical services and behavioral health services that include routine care appointments, urgent care appointments, emergent care, after hours care, and member service and includes those standards in its delegation agreements, if pertinent. 3. The health plan or its delegated entities have an ongoing system to recruit, monitor, and maintain a network of primary care and specialty care providers to meet the health care needs of its members. 4. The health plan, in conjunction with its delegated entities, communicates benefits, services, and network capabilities to its members. 5. The health plan or its delegated entities identify network deficiencies that exist through satisfaction surveys, grievance and complaint logs, and out-of-plan claims, and implements necessary interventions. 6. The health plan or its delegated entities have a process to correct network deficiencies or weaknesses. 7. The health plan or its delegated entities communicate with members about access to primary and specialty providers, mental health and substance abuse providers, and mechanisms to identify specialty care providers who may also serve as PCPs. 8. The health plan or its delegated entities define the types of providers that can be used when more than one type of provider can furnish a particular item or service. 9. The health plan re-evaluates compliance with its policies and procedures for access and available care after each corrective action to ensure that improvement has occurred. This also includes re-evaluation of the delegated entities compliance as pertinent. Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 4, 5 or 6 of 9 elements are 3 of 9 elements are 2 or fewer elements are 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 38

51 05: Network Adequacy B. The organization has a specialty network that ensures the availability of services and implementation of interventions as appropriate for identified issues of network adequacy. 1. The health plan, with its delegate entities (if relevant), has established a network development plan that outlines specialty service needs. 2. The health plan or its delegated entities monitor the availability of specialty services within its network. 3. The heath plan or its delegated entities initiate interventions if adequate specialty services are not available within its network. 4. The heath plan or its delegated entities communicate the process for obtaining specialty services outside of the network to its members (as appropriate). 5. The health plan, with its delegated entities (if relevant), conducts a review of member satisfaction surveys including an analysis of member satisfaction with the organization s specialty network. 6. The health plan, with its delegated entities (if relevant) conducts a review of provider satisfaction surveys including an analysis of provider satisfaction with the organization s specialty network. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is C. The organization has established policies and procedures related to access to care that is made known to the membership and provider network. 1. The health plan or its delegated entities ensure member access to services, including behavioral health, as follows: a. Regular and routine care appointments. b. Urgent care appointments. c. Out of network providers. d. Women s health services, if applicable. e. After-hours care. f. Telephone services for its customer services department and provider sites. 2. The health plan or its delegated entities collect and analyze performance data for member access to health care and services, and consideration is given to race, ethnicity, and cultural and spiritual needs of its members. 3. The health plan or its delegated entities have an ongoing monitoring and recruitment system to ensure compliance with its access and availability standards ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 39

52 05: Network Adequacy (continued) 4. The health plan or its delegated entities collect and analyze member complaints and satisfaction data to determine the level of member satisfaction with access and availability of clinical care and services. 5. The health plan intervenes to correct substandard performance or ensures its delegated entities implement interventions to correct identified issues. Fully Substantially Partially Minimally Non- 8 or 9 of 10 elements are 5, 6 or 7 of 10 elements are 3 or 4 of 10 elements are 2 or fewer elements are D. The organization through its governing body ensures the establishment and compliance with all contracts and/or arrangements affecting all medical services and other medically necessary care provided under its auspices and ensures that services are provided in a safe and effective manner. The health plan, in conjunction with its delegated entities (if relevant), establishes and approves contracts and ensures compliance: 1. Network providers. 2. Imaging services. 3. External laboratories, including pathology services. 4. Hospitals, skilled nursing facilities, behavioral health providers, urgent care, and other such providers. 5. Pharmacy services, e.g. pharmacy benefit manager (PBM). 6. Entities providing after-hours member care arrangements including behavioral health. 7. Contracts with the Office of Personnel Management (OPM) as appropriate. Fully Substantially Partially Minimally Non- 5 or 6 of 7 elements are 3 or 4 of 7 elements are 2 of 7 elements are 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 40

53 05: Network Adequacy E. The organization provides for accessible and available health services, ensuring information about services when provider network practice sites are not open. 1. The member handbook of the health plan or its delegated entities outlines how members can access services after provider network site hours. 2. The health plan or its delegated entities implement policies and procedures regarding the provision of after-hours services and monitors its provider network for compliance. Fully Substantially Partially Minimally Non- No scoring option. 1 of 2 elements is No scoring option. Neither element is F. When the need arises, reasonable attempts are made for health care professionals and other staff to communicate in the language or manner primarily used by patients. 1. The health plan has procedures in place to ensure that members have access to providers who communicate in the language or manner used by them. This requirement is outlined in contracts with delegated entities and compliance is monitored on at least an annual basis. 2. Members, including those with hearing or visual impairments, are offered appropriate methods to communicate with providers and staff of the plan or delegated entities. 3. The health plan or its delegated entities have a provider network that provides interpretive services for members as appropriate. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 41

54 06: Case Management and Care Coordination An accreditable organization provides high-quality health care services in accordance with the principles of professional practice and ethical conduct, and with concern for the cost of care and medical appropriateness. Additionally, an accreditable organization should make efforts to support the empowerment of patients to actively participate in their own wellness, thus improving the community s health status. On-site review of provider medical records during a survey occurs only when required by state regulation, or when a surveyed health plan organization owns and operates clinics where the delivery of care to members takes place. In such instances the survey chair will identify the site and required records sample based on state regulation or AAAHC procedure. of medical record review is not included in the overall evaluation of the health plan in either instance. Results of medical records review will be shared as part of the final report but evaluation of compliance with the Standards of Chapter 6 will not include these results. An accreditable health plan organization has the following characteristics: A. The organization is responsible for ensuring a member s continuity of care through availability of member medical information, referrals, transitions of care, and compliance to state and Federal regulations. The health plan or its delegated entities ensure a member s continuity of care by: 1. Obtaining records from the other provider(s) or organization and incorporating into the member s clinical record. 2. Transferring medical information and records to the other health care professional(s) or consultant(s) and, as appropriate, to the organization where future care will be provided. 3. Confirming that referrals and consultations are disease or procedure-specific. 4. Proactively planning, coordinating, and documenting transitions of care (e.g., ambulatory to inpatient or extended care) in the clinical record. 5. Adopting policies and procedures that ensure new members retain provider continuity as deemed by state and Federal regulatory requirements. Fully Substantially Partially Minimally Non- 4 of 5 elements are 3 or 4 of 5 elements are 2 of 5 elements are 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 42

55 06: Case Management and Care Coordination B. The organization is responsible for ensuring comprehensiveness of care to the members through its services, network, and knowledge of the community. 1. The health plan or its delegated entities ensure that its scope of services include at least, but is not limited to: a. Preventive care including surveillance, anticipatory medical and oral health care guidance, and age-appropriate screening, including well baby care (as appropriate). b. Wellness care including healthy lifestyle issues such as appropriate sleep, stress relief, weight management, healthy diet, oral care, and others (as appropriate). c. Health risk appraisal and health risk assessment of the member at enrollment and periodically thereafter as appropriate. d. Acute illness and injury care. e. Chronic illness management. f. End-of-life care. 2. The health plan or its delegated entities demonstrate knowledge of community resources that support needs of members (and their family, as appropriate) and ensures its provider network has access to these services. 3. The community s service limitations are known by the health plan or its delegated entities and alternate sources are coordinated through the provider network. 4. The needs of the member s personal caregiver, when known, are assessed and addressed to the extent that they affect the care of the member as demonstrated in the medical record. Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 4, 5 or 6 of 9 elements are 3 of 9 elements are 2 or fewer elements are C. The organization must have an established and approved Utilization Management (UM) Program. 1. The UM program of the health plan or its delegated entities has been reviewed by the governing body. 2. The UM program of the health plan or its delegated entities is reviewed at least annually, thereafter. 3. The UM program of the health plan or its delegated entities includes a written description of the scope that includes physician involvement in all aspects of the program. 4. The UM program of the health plan or its delegated entities clearly defines roles and responsibilities of all staff and physicians involved in UM decision-making. 5. The UM program of the health plan or its delegated entities includes involvement of clinical peers (physicians, including behavioral health practitioners) to review denials based on medical necessity and appropriateness. 6. The UM program of the health plan or its delegated entities applies HIPAA privacy and confidentiality standards to all staff and physician reviewers ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 43

56 06: Case Management and Care Coordination Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is D. The written UM program outlines specific requirements related to medical management of the membership. The written UM program (of the health plan or its delegated entities) includes, at least, but is not limited to: 1. An outline of the process to determine medical necessity, benefit coverage, and criteria utilized. 2. A process to develop decision protocols that are based on medical evidence and include provider input. 3. Involvement of clinical peers, including behavioral health practitioners, to review denials based on medical necessity/appropriateness. 4. Ongoing analysis for over/underutilization of services. 5. Effective mechanisms that ensure consistent application of UM review criteria through establishment of inter-rater reliability review. 6. A program that is not structured to provide inappropriate incentives for denial (e.g., no money paid for denial of medical necessary services), limitation, or discontinuation of authorized services. 7. The provision that providers are not prohibited from advocating on behalf of members with the UM process. 8. Representation from the provider network in the development and adoption of UM criteria. 9. Representation from the provider network in the development, adoption, and evaluation of its new medical technology program. 10. Establishment of a pharmaceuticals management program that promotes safety in medication management. 11. Review of criteria used in UM decision-making at least annually and a process to make those criteria available to practitioners. 12. Monitoring of consistent application of criteria and implementation of corrective action(s) to address variances. 13. Analysis of variances along with corrective actions that are reported to the governing body at least annually. 14. Behavioral health care processes that include behavioral health practitioners in implementing appropriate UM components. 15. Delegation oversight at least annually to ensure compliance when the organization delegates any UM activities. 16. At least annual review and analysis of member and provider satisfaction data and a report of the findings to the plan s governing body and QI committee (if applicable) ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 44

57 06: Case Management and Care Coordination Fully Substantially Partially Minimally Non- 12 to 15 of 16 elements are 8 to 11 of 16 elements are 5 to 7 of 16 elements are 4 or fewer elements are E. UM Policies and Procedures are developed that ensure consistency in decision-making and evaluation of care. The health plan or its delegated entities develop and adopt policies and procedures related to UM activities and the UM program for at least: 1. Evaluation of medical necessity. 2. Ensuring physician input into criteria development and/or adoption. 3. Identification of information sources. 4. Defining how monitoring of over/underutilization is conducted. 5. Review and approval of processes used to provide medical services. 6. The use of physicians and other licensed health care professionals including behavioral health practitioners in medical necessity decisions including all denials. 7. Defining timeframes that comply with state or Federal regulations for decision-making regarding: a. urgent care pre-service. b. non-urgent care pre-service. c. concurrent care. d. post-service care. 8. Appeal processes that comply state and Federal requirements. 9. New medical technologies, medical procedures, and new devices and drugs, including pharmaceutical management program (if applicable) and how evaluated. Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 4, 5 or 6 of 9 elements are 3 of 9 elements are 2 or fewer elements are 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 45

58 06: Case Management and Care Coordination F. The organization has written referral policies and procedures that are clearly outlined to the member and provider network. 1. The health plan or its delegated entities develop and implement policies and procedures for its prior authorization and referral processes. 2. The health plan or its delegated entities communicate these policies and procedures to its members. 3. The health plan or its delegated entities communicate these policies and procedures to its provider network. 4. The health plan or its delegated entities collect and analyze member satisfaction data related to prior authorization and referral processes. 5. The health plan or its delegated entities collect and analyze provider satisfaction data related to prior authorization and referral processes 6. The health plan or its delegated entities include, through documented policies and procedures, a process for specialty providers to communicate their clinical findings to the referring provider. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is G. The organization ensures the provision of referral and necessary services for behavioral health and substance use. 1. The health plan or its delegated entities outline how necessary services are obtained through referrals and triage evaluation for behavioral health and substance use services. 2. The health plan or its delegated entities involve behavioral health practitioners in assessment and decision-making activities. 3 The organization adopts access standards for behavioral health and substance abuse as follows: a. Routine care is available within 10 business days. b. Urgent care is available within 48 hours. c. Non-life threatening emergency care is available within 6 hours. d. Life-threatening emergency care is available 24 hours/7 days per week. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 46

59 06: Case Management and Care Coordination H. The organization has chronic/complex case management and disease management programs. 1. The health plan or its delegated entities have identified chronic conditions for management. 2. The health plan or its delegated entities encourage participation of eligible members in established chronic condition programs. 3. The chronic condition program includes at least: a. Case management. b. Member education. c. Opportunities to opt-in or opt-out. d. Provider coordination. e. Development of clinical practice guidelines and preventive health performance measures related to identified chronic conditions. 4. The health plan or its delegated entities collect and analyze data from the chronic condition program s performance. 5. The health plan or its delegated entities implement needed corrective actions and ensure reporting of these efforts through QI activity summaries. Fully Substantially Partially Minimally Non- 7 or 8 of 9 elements are 4, 5 or 6 of 9 elements are 3 of 9 elements are 2 or fewer elements are I. Clinical practice guidelines/protocols and preventive health guidelines are adopted. 1. The health plan or its delegated entities adopt written and approved clinical practice and preventive health guidelines/performance measures that are based on current medical evidence. 2. The health plan or its delegated entities have a process that uses its member demographics in the selection of clinical practice and preventive health guidelines/performance measures. 3. The health plan or its delegated entities have a process that includes practicing network providers in the development and adoption of clinical practice and preventive health guidelines/performance measures. 4. The health plan or its delegated entities review and revise clinical practice and preventive health guidelines/performance measures at least every 2 years. 5. The health plan or its delegated entities communicate its clinical practice and preventive health guidelines/performance measures to the network providers through newsletters, the provider manual, and/or the website. 6. The health plan or its delegated entities analyze performance against clinical practice and preventive health guidelines/performance measures. 7. The health plan or its delegated entities implement corrective action in cases of substandard performances against clinical practice and preventive health guidelines/ performance measures ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 47

60 06: Case Management and Care Coordination Fully Substantially Partially Minimally Non- 5 or 6 of 7 elements are 3 or 4 of 7 elements are 2 of 7 elements are 1 or no element is J. The organization has a process in place that ensures the provider network develops and maintains a system for the proper collection, processing, maintenance, storage, retrieval, and distribution of clinical records and that an individual clinical record is created for each member receiving care. 1. The health plan or its delegated entities adopt written policies related to the development and maintenance of member information and clinical records and communicate these to the network providers. 2. The health plan or its delegated entities have provider contracts that permit the plan or its delegated entities, access to the clinical records of its members. 3. The health plan or its delegated entities have a clinical records policy that applies to electronic records as well as paper records and addresses, at least the maintenance of records, storage or records, confidentiality of records, retrieval of records, and release of records. 4. Individual clinical records are created for each member receiving care. 5. Policies require that each clinical record includes at least patient identifiers (name/id number/ date of birth/gender/responsible party, if applicable), histories and physicals, progress notes, clinical impressions, working diagnosis, and other pertinent information (e.g., lab, x-ray reports, studies ordered, care rendered, medications, disposition, education, missed appointments, etc.) for continuity of care. 6. Policies outline requirements for confidentiality of documentation of clinical, social financial, and other information and the record is protected from loss, tampering, alteration, destruction, and unauthorized or inadvertent disclosure. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 48

61 06: Case Management and Care Coordination K. The organization must establish a program within its provider network that ensures a safe and sanitary practice environment and methods for identifying and preventing infections and complies with state and federal fire prevention regulations and building codes and regulations and have an emergency and disaster preparedness plan to address internal and external emergencies. 1. The health plan or its delegated entities establish program requirements through the Provider Manual for identifying and preventing infections in accordance with nationally recognized standards such as those of the CDC, and reporting of untoward events to the proper authorities. 2. The health plan or its delegated entities ensure that the provider network offices provide education to its staff on identifying and preventing infections through such processes as appropriate hand hygiene and safe injection practices. 3. The health plan or its delegated entities ensure that the provider network offices implement a safety program that contains processes for management of threats, hazards, near misses, and other safety concerns, and that includes monitoring products such as medications, reagents, and solutions that carry an expiration date. 4. The health plan or its delegated entities ensure that the provider network has processes for reduction and avoidance of medication errors and prevention of falls or physical injuries involving patients, staff, and all others. 5. The health plan has emergency and disaster preparedness plans to address internal and external emergencies for its administrative offices that includes an evacuation plan and meeting location. 6. The health plan or its delegated entities ensure that each network provider location has an emergency and disaster preparedness plan in place that ensures member safety and includes an evacuation plan. 7. The health plan ensures it corporate headquarters complies with applicable state and local fire prevention regulations or other federal requirements. 8. The health plan or its delegated entities ensure that the facilities where the network providers deliver health care services to its members comply with state and local fire prevention regulations or any other federal requirements. Fully Substantially Partially Minimally Non- 7 of 8 elements are 5 or 6 of 8 elements are 3 or 4 of 8 elements are 2 or fewer elements are 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 49

62 07: Health Education & Wellness Promotion All health care organizations will provide or make available health education and health promotion services to meet the needs of the membership served. These services will be provided in accordance with ethical and professional practices and legal requirements. Such an organization has the following characteristics: A. The organization provides health education and wellness promotion services for members. 1. The health education and wellness promotion services offered to members by the health plan or its delegated entities are provided by personnel that have, at least: a. Necessary and appropriate training, education, credentials, skills and continuing education in health education and wellness promotion to carry out their responsibilities. b. Access to and ability to utilize consultative services, as appropriate. 2. The health education and wellness promotion services offered to members by the health plan or its delegated entities have defined educational goals and objectives. 3. The health plan or its delegated entities conduct an evaluation to determine if the health education and wellness promotion program goals and objectives have been met. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is B. The organization s health education and disease prevention programs are based on a complete needs assessment for the population served. 1. The health plan or its delegated entities periodically conduct a complete needs assessment for the population served for the purpose of health education and disease prevention program development. 2. The health plan or its delegated entities evaluate relevant health risks and health education needs through health risk assessments or other such information. 3. The health plan or its delegated entities utilize all data or resources available to compile health risk and needs information. 4. The health plan or its delegated entities quantify risk and needs whenever possible through health risk assessments ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 50

63 07: Health Education & Wellness Promotion (continued) 5. The health education and disease management programs of the health plan or its delegated entities are comprehensive and consider the medical, psychological, social and cultural needs of the population. 6. The health plan or its delegated entities provide a wide range of health education and wellness service programs that are relevant to its population and include, at least: a. Disease-specific screening and educational programs. b. Substance abuse prevention and education, including programs related to alcohol, tobacco, and other drugs. c. Promotion of healthy eating, physical fitness, and weight management. d. Sexual, physical, and emotional violence prevention. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is C. The organization facilitates the education of, and effective communication with, members served concerning the diagnosis and treatment of their conditions, appropriate preventive measures, and coordination of health care services. 1. The health plan or its delegated entities maintain member newsletters for effective communication. 2. The health plan or its delegated entities maintain Evidence of Coverage literature and benefits descriptions containing accurate information. 3. The health plan or its delegated entities make health education and wellness promotion materials available to members and providers electronically, in downloadable, printable media, or hard copy delivered by mail if requested. 4. The health plan or its delegated entities offer material to its members and providers in established threshold languages and through established interpreter services. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 51

64 07: Health Education & Wellness Promotion D. Health education and wellness promotion services are referenced or documented in the member s clinical record. 1. The health plan has policies and procedures to ensure that health education and wellness services, whether they occur within the context of a clinical visit or not, are referenced or documented in the clinical records. These policies and procedures are included in delegation agreements and monitoring of compliance is conducted through audits at least annually. 2. The health plan or its delegated entities communicate its policies to its provider network. 3. Medical record reviews monitor compliance with this documentation requirement. 4 The health plan or its delegated entities initiate interventions when providers do not comply with policies and procedures for documentation of this activity. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is E. The organization has policies and processes to assess satisfaction with the health education and wellness promotion services. 1. The health plan has established policies and procedures to assess member and provider satisfaction with the health education and wellness promotion services. These policies and procedures are outlined in delegation agreements and compliance is monitored in conjunction with auditing at least annually. 2. The health plan or its delegated entities ensure compliance with the policies and procedures by assessing satisfaction of members and providers with health education & wellness promotion. 3. Results of the surveys are reported and incorporated into the QI activities reporting within the health plan. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 52

65 07: Health Education & Wellness Promotion F. The organization encourages network providers to support educational programs and activities for members and office staff. 1. The health plan or its delegated entities ensure that its provider offices provide convenient access to reliable, up-to-date information pertinent to the clinical, educational, and administrative services. 2. The health plan or its delegated entities ensure that its provider offices encourage participation in educational activities that includes members and its office staff. 3. The health plan or its delegated entities ensure that educational programs are consistent with the organization s mission, goals, and objectives. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 53

66 08: Quality Improvement and Management In striving to improve the quality of care and to promote more effective and efficient utilization of facilities and services, an accreditable organization maintains an active, integrated, organized, ongoing, datadriven, peer-based program of quality management and improvement that links quality improvement activities, clinical performance measures, and risk management in an organized, systematic way. Subchapter I Quality Improvement Program: An accreditable organization maintains an active, integrated, organized, and peer-based quality improvement (QI) program as evidenced by the following characteristics: A. The organization has a quality improvement (QI) program that is broad in scope to ensure ongoing quality and improvement of performance when needed. The health plan has a written QI program description that includes, at least, items listed in 1 through 8 below. The program requirements and expectations are outlined in the delegation agreements and compliance is monitored by the plan during audits conducted at least annually. 1. The scope of the health plan s and its delegated entities health care delivery services and how the QI plan for these services is assessed. 2. A scope that addresses clinical, administrative and cost-of-care performance issues and member outcomes including safety. 3. The identification of the specific committee(s) or individual(s) responsible for the development, implementation, and oversight of the program. 4. Demonstration of participation in the program by health care professionals, including behavioral health practitioners, one or more of whom is a physician from the provider network. 5. Goals and objectives for the overall program including goals for serving cultural and linguistic needs of the population as a whole, and of members with complex health needs. 6. Processes to identify appropriate problems or concerns to address for improving the quality of services provided by the organization. 7. Identification of QI activities such as studies (including methods for performing internal and external benchmarking) to support the goals of the program. 8. Education and disease prevention programs that are incorporated into the quality improvement and management activities. Fully Substantially Partially Minimally Non- 7 of 8 elements are 5 or 6 of 8 elements are 3 or 4 of 8 elements are 2 or fewer elements are 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 54

67 08: Quality Improvement and Management B. The QI program and work plan are reviewed and approved by the governing body at least annually. The health plan s governing body reviews and approves the QI program and work plan annually. Fully Substantially Partially Minimally Non- Element is No scoring option. Element is not C. The organization s QI activities demonstrate systems that ensure identification of problems and concern and incorporate various performance measures, risk management issues, and network provider issues and monitoring. 1. The health plan and its delegated entities (if relevant) use quality improvement activities that include methods for internal and external benchmarking to identify opportunities for improvement studies/initiatives that support the goals of the program. 2. The health plan along with its delegated entities (if relevant), demonstrate evidence of links between quality improvement activities, performance measures, the risk management program, and provider network performance related to re-credentialing and/or other issues. 3. The health plan along with its delegated entities (if relevant), develop an outline of annual activities such as a work plan. 4. The health plan along with its delegated entities (if relevant), conduct an evaluation of the overall effectiveness of the program at least annually. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 55

68 08: Quality Improvement and Management D. The organization s QI activities are appropriately reported throughout the organization. 1. The organization along with its delegated entities demonstrate evidence that findings from quality improvement activities are reported to the FEHB health plan s governing body and throughout the organization on an ongoing basis. 2. The health plan or its delegated entities demonstrate evidence that findings from the quality improvement activities are reported to the provider network on an ongoing basis. 3. The health plan or its delegated entities demonstrate evidence that findings from the quality improvement activities are reported to the membership on an ongoing basis. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is E. The organization, with active participation of the provider network, including behavioral health providers, conducts ongoing, comprehensive assessments of the quality of care provided. Such assessments include results of medical necessity and appropriateness of care review as determined throughout the organization s quality improvement activities. 1. The health plan or its delegated entities include physicians from its the provider network, including behavioral health, in its ongoing quality improvement activities 2. The health plan or its delegated entities demonstrate ongoing and comprehensive assessment of the quality of care provided to the members that includes evaluation of medical necessity and appropriateness of care provided. 3. The health plan or its delegated entities demonstrate incorporation of quality improvement outcomes and findings in revision of policies, scope of services provided, and improvement activities. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 56

69 08: Quality Improvement and Management F. The organization, with involvement of health care providers including behavioral health providers, develops criteria and conducts ongoing monitoring of important aspects of the care provided by physicians and other health care professionals along with member demographic information. 1. The health plan or its delegated entities include network providers (including behavioral health providers) in developing criteria for monitoring the delivery of care. 2. The health plan along with its delegated entities demonstrate that it collects data annually to determine member demographics and care needs. 3. The health plan along with its delegated entities determine its QI initiatives for monitoring annually. 4. The health plan along with its delegated entities include clinical care and services in its QI monitoring activities. 5. The health plan along with its delegated entities develop and implement identifiable and measurable criteria that support its system of ongoing data collection using, at a minimum, those measures as required by the Office of Personnel Management (OPM). 6. The health plan along with its delegated entities conduct ongoing monitoring of important aspects of the care provided by physicians and other health care professionals. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is G. The organization must demonstrate the ongoing collection and periodic evaluation of care to identify acceptable or unacceptable trends or occurrences that affect member outcomes. 1. The health plan along with its delegated entities demonstrate ongoing collection of data related to established criteria to measure the clinical performance of its provider network and to identify acceptable or unacceptable trends or occurrences that affect member outcomes. 2. The health plan along with its delegated entities analyze data at least annually to identify trends in performance, accomplishment of performance goals, and to identify unacceptable performance. 3. The health plan along with its delegated entities conduct critical analyses of its QI initiatives for sustained improvement annually. 4. The health plan or its delegated entities communicate QI performance to its provider network. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 57

70 08: Quality Improvement and Management H. The organization adopts a quality improvement process that demonstrates the following elements in its quality improvement initiatives. 1. The QI initiatives/projects include a statement of the purpose that identifies the process or situation being reviewed or a known or suspected problem, and explains why it is significant to the organization. 2. The QI initiatives/projects identify performance goals against which the organization will compare its current performance in the area of study. 3. The QI initiatives/projects describe the data that will be collected in order to determine current performance. 4. The QI initiatives/projects demonstrate evidence of data collection. 5. The QI initiatives/projects include data analysis that describes findings about the frequency, severity, and source(s) of the problem(s). 6. The QI initiatives/projects include a comparison of the organization s current performance in the area of study to the previously identified performance goal. 7. The QI initiatives/projects demonstrate implementation of corrective action(s) or improvement efforts to resolve identified problems. 8. The QI initiatives/projects include re-measurement to objectively determine whether the corrective actions have achieved and sustained measurable improvement. 9. The QI initiatives/projects demonstrate implementation of additional corrective action(s) and continued re-measurement if the initial corrective action(s) did not achieve and/or sustain the desired improved performance, until the problem is resolved or is no longer relevant. 10. The QI initiatives/projects findings and outcomes are communicated to the governing body and throughout the organization, as appropriate, and there is evidence that the findings are incorporated into the organization s educational activities. Fully Substantially Partially Minimally Non- 8 or 9 of 10 elements are 5, 6 or 7 of 10 elements are 3 or 4 of 10 elements are 2 or fewer elements are 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 58

71 08: Quality Improvement and Management I. The organization demonstrates analysis of care provided to members on an ongoing basis. 1. The QI activities of the health plan or its designated entities include ongoing analysis of the results of peer review activities that include evaluation of various peer review indicators. 2. The health plan along with its delegated entities demonstrate that outcomes data is collected and analyzed on an ongoing basis to determine areas for improvement. 3. The health plan along with its delegated entities incorporate both internal and external benchmarks into the QI process through physician and/or health plan report cards using health care outcomes data, member satisfaction data, member complaints/grievances, and/ or other such data. 4. The health plan along with its delegated entities demonstrate implementation of improvement efforts as appropriate based on analysis of the above data and quality indicators. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is J. The organization participates in internal and external benchmarking activities that compare key performance measures with other similar organizations or with recognized national or professional targets or goals. 1. The benchmarking system of the health plan and its delegated entities includes, at least: a. The use of selected indicators based on a systematic, ongoing collection, and analysis of data. b. Systematic collection and analysis of data related to the selected performance measure. c. Use of benchmarks that are based on valid and reliable local, state, national, or published data. d. Measured changes in performance. e. Demonstrated sustained performance improvement over time. 2. There is evidence that results of benchmarking activities are incorporated into QI activities of both the FEHB health plan and its delegated entities. 3. The results of benchmarking activities are reported to the governing body of the health plan and the delegated entities (if relevant), throughout the organization, and to the provider network. Fully Substantially Partially Minimally Non- 5 or 6 of 7 elements are 3 or 4 of 7 elements are 2 of 7 elements are 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 59

72 08: Quality Improvement and Management K. The organization facilitates the provision of high-quality health care as demonstrated by monitoring of continuity and coordination of care and member and provider satisfaction data. 1. The health plan and its delegated entities (if relevant), demonstrate evaluation of the continuity and coordination of care across the delivery system. 2. The health plan and its delegated entities (if relevant), demonstrate evaluation of member satisfaction data as a component of the QI program. 3. The health plan and its delegated entities (if relevant), demonstrate evaluation of provider satisfaction data as a component of the QI program. 4. The heath plan and its delegated entities (if relevant), demonstrate implementation of improvement efforts when continuity and coordination of care or member or provider satisfaction issues are identified. Fully Substantially Partially Minimally Non- 3 of 4 elements are 2 of 4 elements are 1 of 4 elements is No element is Subchapter II Risk Management: An accreditable organization develops and maintains a program of risk management, appropriate to the organization, designed to protect the life and welfare of an organization s members and employees. Such an organization has the following characteristics: A. The organization, through its governing body, is responsible for establishing and overseeing a comprehensive program of risk management. 1. The health plan develops and implements a risk management program. 2. The governing body reviews and approves the risk management program. 3. The health plan, working in conjunction with its delegated entities, ensures coordination of its risk management activities with its QI program. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 60

73 08: Quality Improvement and Management B. The organization has a designated person or committee responsible for implementation and ongoing management of the risk management program. 1. The health plan assigns responsibility for the risk management program to a specific individual or committee. 2. The health plan defines the reporting structure for risk management activities. Fully Substantially Partially Minimally Non- No scoring option. 1 of 2 elements is No scoring option. Neither element is C. The organization s risk management program addresses safety of members and other important issues. The health plan, in conjunction with its delegated entities (if relevant), has a written risk management program the description of which includes, at least: 1. Consistent application of the risk management program throughout the health plan, including all departments, all service locations, and within the delegated entities. 2. Methods by which a member may be dismissed from care or refused care. 3. Reporting, reviewing, and appropriate analysis of all incidents reported by staff, members, health care professionals, and others that may include all deaths, trauma, or other adverse incidents as referenced in 8.II.D and reporting as may be required by state regulations. 4. Periodic review of all litigation involving the health plan and its staff and health care professionals. 5. Review of member complaints/grievances. 6. Handling of impaired health care professionals. 7. Establishment and documentation of coverage after normal working hours. 8. Methods for prevention of unauthorized prescribing. 9. Monitoring for fraud, waste, and abuse. 10. Processes for routine clinical records audits that include risk management review principles and how results are used during the provider re-credentialing process as conducted by delegated entities, if pertinent. Fully Substantially Partially Minimally Non- 8 or 9 of 10 elements are 5, 6 or 7 of 10 elements are 3 or 4 of 10 elements are 2 or fewer elements are 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 61

74 08: Quality Improvement and Management D. The organization establishes policies and systems for the identification, reporting, analysis, and prevention of adverse incidents. 1. The health plan s policies provide for a definition of an adverse incident that includes at least the following, and there is evidence that delegated entities are aware of these policies: a. An unexpected occurrence during a health care encounter involving member death or serious physical or psychological injury or illness, including loss of limb or function, not related to the natural course of the member s illness or underlying condition. b. Any process variation for which a recurrence carries a significant chance of a serious adverse outcome. c. Events such as actual breaches in medical care, administrative procedures or others resulting in an outcome that is not associated with the standard of care or acceptable risks associated with the provision of care and service for a member, including reactions to drugs and materials. d. Circumstances or events that could have resulted in an adverse event ( near miss events). 2. The health plan, in conjunction with its delegated entities (if relevant), demonstrates that it reviews the frequency of occurrences and severity of outcomes for reportable events. 3. The health plan, in conjunction with its delegated entities (if relevant), has a process for conducting a thorough analysis when an adverse incident occurs in order to identify the basic or causal factors (root cause analysis) that underlie variation in performance, including the occurrence or possible occurrence of an adverse incident. 4. The health plan, in conjunction with its delegated entities (if relevant), identifies potential improvements in processes or systems that would tend to decrease the likelihood of such incidents in the future, or determines, after analysis, that no such improvement opportunities exist. 5. The health plan, in conjunction with its delegated entities (if relevant), develops an action plan that identifies the strategies that it intends to implement to reduce the risk of similar incidents occurring in the future and addresses responsibility for implementation, oversight, pilot testing as appropriate, timelines, and strategies for measuring the effectiveness of the actions. 6. The health plan has a mechanism to report through established channels within the plan itself and, as appropriate, to external agencies in accordance with law and regulation. Fully Substantially Partially Minimally Non- 5 of 6 elements are 3 or 4 of 6 elements are 2 of 6 elements are 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 62

75 08: Quality Improvement and Management E. The organization ensures education in risk management activities is provided to all staff. 1. There is evidence of risk management training provided to all health plan staff within 30 days of employment and delegated entities demonstrate that such training occurs during their staff orientation. 2. There is evidence of risk management training provided to all health plan staff annually thereafter (and more frequently as may be needed) and delegated entities demonstrate that such training occurs annually. 3. There is evidence that the risk management program is communicated to the provider network through the provider manual or the website of the plan or its delegated entities. Fully Substantially Partially Minimally Non- No scoring option. 2 of 3 elements are No scoring option. 1 or no element is 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 63

76 Summary Table Indicate your organization s compliance level for the chapters and use this information to identify and prioritize areas for attention. FC SC PC MC NC N/A 1: Member Rights, Responsibilities and Protections 2: Governance 3: Administration 4: Provider Network Credentialing 5: Network Adequacy 6: Case Management and Care Coordination 7: Health Education & Wellness Promotion 8: Quality Improvement and Management I. Quality Improvement Program II. Risk Management 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 64

77 Tools

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79 Organizations are expected to develop an application document appropriate to the operations and services provided. This is a sample document for reference only and is not available in template format. Sample Application for Privileges (Organization Name) (Street Address) (City, State and ZIP Code) Instructions: 1. Information must be typed or printed. 2. All questions must be answered and forms must be signed where indicated. Please initial the bottom of each page of this application. 3. If more space is needed, please attach additional sheets and reference the questions being answered. 4. If there is a break in the continuity of your medical education, internship, residency, hospital affiliations, medical practice, etc., please explain. 5. Please return the following with your application: a. Curriculum vitae b. Copy of your current state license c. Current IRS W-9s, if applicable d. Copy of narcotic registration (federal/state) (DEA and CDS) e. Request for Privileges (completed and signed) f. Copy of front sheet of professional liability insurance policy including applicant s name, effective date, expiration date, and policy limits g. Copy of Board Certification (if applicable) h. Copy of professional school/diploma, residency certificates, and Fellowship certificates i. Copy of hepatitis-b vaccination or waiver j. Copy of most recent tuberculosis PPD test, if applicable k. Current CLIA certificate, if applicable Identifying Information Last Name (Jr., Sr., etc.) First Name Middle S. S. # List other names by which you have been known: Last Name First Name Middle Primary Professional Group Name and Address Years Associated (YYYY-YYYY) City State ZIP Telephone Number Fax Number Home Address Home Telephone Number City State ZIP Alternate Telephone Number Date of Birth Place of Birth Citizenship Physician Providing Coverage Telephone Number Fax Number Cell Phone Medicare Unique Provider ID Number NPI Number Medicaid Number Medical Licensure/Certification State License Number Original Date of Issue (mm/dd/yyyy) Expires (mm/dd/yyyy) Controlled Substances Registration Certification Number (Your State Name) Expires (mm/dd/yyyy) DEA Registration Number Expires (mm/dd/yyyy) Page 1 of 8 Applicant Initials Date 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 65

80 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) Other State Medical Licenses Past and Present: State License Number Original Date of issue (mm/dd/yyyy) State License Number Original Date of Issue (mm/dd/yyyy) Do you currently practice in this state? Yes No Explain: Pre-Medical Education College/University Degrees/Honors Address Date of Graduation (mm/dd/yyyy) City State ZIP Medical Education Medical/Professional School Degree/Honors Address Date of Graduation (mm/dd/yyyy) City State ZIP Other Professional Education Name of Institution Degree/Honors Address Date of Graduation (mm/dd/yyyy) City State ZIP Internship Name of Institution Dates Attended (mm/dd/yyyy-mm/dd/yyyy) Address Full Name of Program Director or Department Chair Type Kind (Medical, Surgical, etc.) Program successfully completed? If no, attach an explanation... Yes No Rotating Straight If straight, list specialty: Were you the subject of any disciplinary actions during your attendance at this institution? If yes, attach an explanation... Yes No If more than one internship, check here and attach additional information including responses to the above items specific to the additional internships. Page 2 of 8 Applicant Initials Date 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 66

81 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) Residency Programs Name of Institution Dates Attended (mm/dd/yyyy-mm/dd/yyyy) Address City State ZIP Type of Residency Full Name of Program Director or Department Chair Program successfully completed? If no, attach an explanation... Yes No Name of Institution Dates Attended (mm/dd/yyyy-mm/dd/yyyy) City State ZIP Type of Residency Full Name of Program Director or Department Chair Program successfully completed? If no, attach an explanation... Yes No Training, Fellowships, Preceptorships, Postgraduate Education List in chronological order. Give complete school or hospital name and address, including ZIP code, beginning and ending dates, and name of your immediate superior. Name of Institution Address City State ZIP Dates Attended (mm/dd/yyyy-mm/dd/yyyy) Name of Immediate Superior Type of Fellowship Did you successfully complete this program? If no, please attach an explanation.... Yes No Were you the subject of any disciplinary actions during your attendance at this institution? If yes, attach an explanation... Yes No Name of Institution Address City State ZIP Dates Attended (mm/dd/yyyy-mm/dd/yyyy) Name of Immediate Superior Type of Fellowship Did you successfully complete this program? If no, please attach an explanation.... Yes No Were you the subject of any disciplinary actions during your attendance at this institution? If yes, attach an explanation... Yes No Name of Institution Address City State ZIP Dates Attended (mm/dd/yyyy-mm/dd/yyyy) Name of Immediate Superior Type of Fellowship Did you successfully complete this program? If no, please attach an explanation.... Yes No Were you the subject of any disciplinary actions during your attendance at this institution? If yes, attach an explanation... Yes No Page 3 of 8 Applicant Initials Date 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 67

82 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) Hospital and University Affiliations List all present and past affiliations in chronological order. Indicate Staff Status as: Active/Courtesy, etc., or Academic Title. Use an additional sheet if necessary. Name of Institution (1) Address City State ZIP Dates Affiliated (mm/dd/yyyy-mm/dd/yyyy) Membership status (Active, Courtesy, Consulting, Adjunct, Suspended/Terminated/Resigned, Active Professional Staff, Senior Staff, Associate, Provisional, Affiliate, Pending, Other [specify]) Department/Division Dept. Chief/Chair (Full Name) Do you currently have privileges at this institution?... Yes No If yes, please list the type of privileges granted (Provisional, Limited, Conditional, etc.). Name of Institution (2) Address City State ZIP Dates Affiliated (mm/dd/yyyy-mm/dd/yyyy) Membership status (Active, Courtesy, Consulting, Adjunct, Suspended/Terminated/Resigned, Active Professional Staff, Senior Staff, Associate, Provisional, Affiliate, Pending, Other [specify]) Department/Division Dept. Chief/Chair (Full Name) Do you currently have privileges at this institution?... Yes No If yes, please list the type of privileges granted (Provisional, Limited, Conditional, etc.). Name of Institution (3) Address City State ZIP Dates Affiliated (mm/dd/yyyy-mm/dd/yyyy) Membership status (Active, Courtesy, Consulting, Adjunct, Suspended/Terminated/Resigned, Active Professional Staff, Senior Staff, Associate, Provisional, Affiliate, Pending, Other [specify]) Department/Division Dept. Chief/Chair (Full Name) Do you currently have privileges at this institution?... Yes No If yes, please list the type of privileges granted (Provisional, Limited, Conditional, etc.). Name of Institution (4) Address City State ZIP Dates Affiliated (mm/dd/yyyy-mm/dd/yyyy) Membership status (Active, Courtesy, Consulting, Adjunct, Suspended/Terminated/Resigned, Active Professional Staff, Senior Staff, Associate, Provisional, Affiliate, Pending, Other [specify]) Department/Division Dept. Chief/Chair (Full Name) Do you currently have privileges at this institution?... Yes No If yes, please list the type of privileges granted (Provisional, Limited, Conditional, etc.). Page 4 of 8 Applicant Initials Date 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 68

83 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) Previous Group/Medical Practice Type of Organization Name of Organization Address City State ZIP Dates Practicing (mm/dd/yyyy-mm/dd/yyyy) Type of Organization Name of Organization Address City State ZIP Dates Practicing (mm/dd/yyyy-mm/dd/yyyy) Type of Organization Name of Organization Address City State ZIP Dates Practicing (mm/dd/yyyy-mm/dd/yyyy) Certification Certified by American Board of (Specialty) Certification # Dates (Certification/Recertification/Expiration) (mm/dd/yyyy) Subspecialty Board Status (Name of Board) Certification # Dates (Certification/Recertification/Expiration) (mm/dd/yyyy) If Not Certified, Give Present Status Date Date of Exam Professional Societies, Awarded Fellowships (ACS, ACP, etc.) List all memberships past, present, or pending in professional societies. Please include dates of membership. Please give complete names and addresses, including ZIP codes in all instances. Attach an additional sheet if necessary. Page 5 of 8 Applicant Initials Date 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 69

84 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) Professional Peer References List three professional references familiar with the applicant s qualifications during the three years immediately preceding this application. One professional reference must be from the Chief of the department or service where the applicant last furnished professional services. Last Name (1) First Middle Degree Title Professional Relationship Specialty Years Known Address City State ZIP Phone Fax Last Name (2) First Middle Degree Title Professional Relationship Specialty Years Known Address City State ZIP Phone Fax Last Name (3) First Middle Degree Title Professional Relationship Specialty Years Known Address City State ZIP Phone Fax Professional Liability Insurance Carrier Address City State ZIP Policy limits Per Occurrence ($) Aggregate ($) Policy # Agent Effective Date (mm/dd/yyyy) Expiration Date (mm/dd/yyyy) Type of coverage: Claims made Occurrence Have any professional liability lawsuits been filed against you during the past ten years (including those closed)?... Yes No Are there any now still pending?... Yes No Has any judgment, payment of claim, or settlement ever been made against you in any professional liability cases?... Yes No Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?... Yes No Have you ever been denied professional insurance, or has your policy ever been cancelled?... Yes No If yes to any of the above, please explain on a separate sheet. Page 6 of 8 Applicant Initials Date 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 70

85 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) Professional Sanctions 1. Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, revoked, canceled, and/or subject to probation either voluntarily or involuntarily, or has your application for a license ever been withdrawn?... Yes No 2. Have you ever been reprimanded and/or fined, been the subject of a complaint, and have you been notified in writing that you have been investigated as the possible subject of a criminal, civil, or disciplinary action by any state or federal agency that licenses providers?... Yes No 3. Have you lost any board certification(s), and/or failed to rectify?... Yes No 4. Have you been examined by a Capital Certifying Board but failed to pass?... Yes No 5. Has any information pertaining to you, including malpractice judgments and/or disciplinary action, ever been reported to the National Practitioner Data Bank (NPDB) and/or any other practitioner data bank?... Yes No 6. Has your federal DEA number and/or state controlled substances license been restricted, limited, relinquished, suspended, or revoked, either voluntarily or involuntarily, and/or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action with respect to your DEA or controlled substance registration?... Yes No 7. Have you, or any of your hospital or ambulatory surgery center privileges and/or membership been denied, revoked, suspended, reduced, placed on probation, proctored, placed under mandatory consultation, or non-renewed?... Yes No 8. Have you voluntarily or involuntarily relinquished or failed to seek renewal of your hospital or ambulatory surgery center privileges for any reason?... Yes No 9. Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending with respect to your hospital or ambulatory surgery center privileges and/or your license?... Yes No 10. Have you ever been reprimanded, censured, excluded, suspended, and/or disqualified from participating, or voluntarily withdrawn to avoid an investigation, in Medicare, Medicaid, CHAMPUS, and/or any other governmental health-related programs?... Yes No 11. Have Medicare, Medicaid, CHAMPUS, PRO authorities, and/or any other third-party payors brought charges against you for alleged inappropriate fees and/or quality-of-care issues?... Yes No 12. Have you been denied membership and/or been subject to probation, reprimand, sanction, or disciplinary action, or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action by any health care organization, e.g., hospital, HMO, PPO, IPA, professional group or society, licensing board, certification board, PSRO, or PRO?.. Yes No 13. Have you withdrawn an application or any portion or an application for appointment or reappointment for clinical privileges or staff appointment or for license or membership in an IPA, PHO, professional group or society, health care entity, or health care plan prior to a final decision to avoid a professional review or an adverse decision?... Yes No 14. Have you been charged with or convicted of a crime (other than a minor traffic offense) in this or any other state or country and/or do you have any criminal charges pending other than minor traffic offenses in this state or any other state or country?... Yes No 15. Have you been the subject of a civil or criminal or administrative action or been notified in writing that you are being investigated as the possible subject at a civil, criminal, or administrative action regarding sexual misconduct, child abuse, domestic violence, or elder abuse?... Yes No If yes to any of the above, please explain on a separate sheet. Health Status 1. Do you have a medical condition, physical defect, or emotional impairment which in any way impairs and/or limits your ability to practice medicine with reasonable skill and safety?... Yes No 2. Are you unable to perform the essential functions of a practitioner in your area of practice, with or without reasonable accommodation?... Yes No If yes to any of the above, please explain on a separate sheet. Page 7 of 8 Applicant Initials Date 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 71

86 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) Chemical Substances or Alcohol Abuse 1. Are you currently engaged in illegal use of any legal or illegal substances?... Yes No 2. Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?... Yes No If yes to any of the above, please explain on a separate sheet. By applying for clinical privileges, I hereby signify my willingness to appear for interviews in regard to my application, and I authorize the Organization, its medical staff, and their representatives to consult with members of management and members of medical staffs of other hospitals or institutions with which I have been associated and with others, including past and present malpractice insurance carriers, who may have information bearing on my professional competence, character, and ethical qualifications. I hereby further consent to inspection by the Organization, its medical staff, and its representatives of all records and documents, including medical and credential records at other hospitals, which may be material to an evaluation of my qualifications for staff membership. I hereby release from liability all representatives of the Organization and its medical staff, in their individual and collective capacities, for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from any liability any and all individuals and organizations who provide information to the Organization or to members of its medical staff in good faith and without malice concerning my professional competence, ethics, character, and other qualifications for staff appointment and clinical privileges. I hereby consent to the release of information by other hospitals, other medical associations, and other authorized persons, on request, regarding any questions the Organization may have concerning me as long as such release of information is done in good faith and without malice, and I hereby release from liability and hold harmless the Organization and any other third party for so doing. I understand and agree that I, as an applicant for clinical privileges, have the burden of producing adequate information for the proper evaluation of my professional competence, character, ethics, and other qualifications and for the resolution of any doubts about such qualifications. By accepting appointment and/or reappointment to the medical staff at (insert organization name), I hereby acknowledge and represent that I have read and am familiar with the bylaws, rules, and regulations of the Organization, as well as the principles, standards, and ethics of the national, state, and local associations and state law and regulations that apply to and govern my specialty and/or profession, which are the Governing Standards. I further agree to abide by such further Governing Standards as may be enacted from time to time. In addition, I agree to notify the Organization of any circumstances that would change my status in licensure, DEA, Medicare participation, liability insurance coverage, board certification status, or hospital privileges. I understand and agree that any significant misstatements in or omissions from this application shall constitute cause for denial of appointment or cause for summary dismissal from the medical staff with no right of appeal. All information submitted by me in this application is true to the best of my knowledge and belief. I further authorize a photocopy or facsimile of the requests, authorizations, and releases to this application to serve as the original. Signature of Applicant Date Print Name Page 8 of ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 72

87 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) RE: (Applicant Name, Title) Temporary Privileges Appointment recommended to the category of staff with the following clinical privileges: As requested As requested with the following changes: Appointment not recommended Executive Director Date Medical Director Medical Executive Committee Appointment recommended to the category of staff with the following clinical privileges: As requested As requested with the following changes: Appointment not recommended Date Medical Executive Committee Member Board of Directors Appointment recommended to the category of staff with the following clinical privileges: As requested As requested with the following changes: Appointment not recommended Date Board of Directors Member 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 73

88 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) RE: (Applicant Name, Title) Dear Sir or Madam: The above practitioner has applied for medical staff appointment (or clinical privileges) to the staff of (Organization Name). The applicant has given your name as a reference, and we are asking you to render an opinion in the following categories. This is an important part of the evaluation of this practitioner s application for clinical staff privileges. Your response will be treated as confidential. Please do not hesitate to call us if you feel your comments could be best expressed directly. Clinical knowledge Clinical judgment Technical proficiency Professional relations with patients Ethical conduct Record keeping Ability to understand and speak English Participation in medical staff affairs Reliable Usually Reliable Problems What is your opinion regarding the applicant s competency in performing the privileges shown on the attachment? Additional comments: Recommendation: Signature Title Date Name (Please print) 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 74

89 Sample Application for Privileges (Organization Name) (Street Address) (City, State, and ZIP Code) Medical Staff Office Regarding the appointment of: (Applicant Name, Title) Dear Sir or Madam: The applicant named above is seeking medical staff privileges at our organization. We would appreciate answers to the questions found below. This physician s current staff status: QUESTIONS Yes No Do Not Know Have this practitioner s privileges been restricted, suspended, revoked, or surrendered? n Has this practitioner s professional performance been within or above the acceptable standard of care within the last two years? n n n Has the practitioner s morbidity rate, mortality rate, infection rate, or complication rate exceeded your organization s criteria for the standards of practice? Has the practitioner been suspended for clinical records violations within the last two years? If yes, how many times? n Has this practitioner s behavior been disruptive to patient care? n Have there been written complaints about this practitioner by patients, hospital staff, or members of the medical staff? n Has the practitioner been subjected to any disciplinary action by this hospital or licensing body during the past two years? n n To the best of your knowledge, has this individual been involved in a malpractice claim or action during the past two years? If yes, please provide us with the information regarding the malpractice claim or action during the past two years. n n n At the appropriate time, will you likely re-appoint this individual to your medical staff? n n nn n n n Thank you for your effort and assistance with this request. Signature Title Date Name (Please print) 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 75

90 Credentialing Records Worksheet (This form may be useful for oversight review of delegated entities.) Organization Date of Visit Instructions: Mark each box as: Provider Identification Number Adequate A Inadequate I Not Applicable N/A Physician (MD/DO), Nurse Practitioner (NP), Physician Assistant (PA), Dentist (DDS), Chiropractor (DC), Podiatrist (DPM), Nurse Midwife The credential file was completed in a timely manner Application present with signed & dated attestation & release (not exceeding 180 days from signing to credentialing approval date) Core privileges granted is documented State medical license or non-physician license/certification verified DEA Certificate present & verified Education & training verified using AAAHC-acceptable verification sites Evidence of peer review present Board certification verified, if applicable NPDB queried Presence of current malpractice insurance, if required Professional liability claims history verified The organization verified the existence / non-existence of Board sanctions The organization verified the existence / non-existence of Medicare/Medicaid sanctions Reappointment process completed within the timeframe specified by the organization s bylaws in accordance with AAAHC Standards or state law, whichever is more stringent Provide additional comments, including provider ID number, below Please provide comments, if applicable, about any problems noted during review of credentials files 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 76

91 Credentialing Records Worksheet Please provide comments, if applicable, about any problems noted during review of credentials files Signature of Surveyor 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 77

92 Personnel Records Worksheet Organization Location Date of Visit Instructions: Mark each box as: Personnel Identification Number Adequate A Inadequate I Not Applicable N/A Job application/resume present Signed & dated job description present Orientation and orientation checklist completed within 30 days of hire Employee signed acknowledgement of receipt of personnel policies I-9 (immigration and Naturalization Form) Verification of professional license/certification Corporate compliance & HIPAA training documented Periodic evidence of performance evaluation(s) that are acknowledged by employees Continuing/in-service educational records Provide additional comments, including personnel ID number, below: Please provide comments, if applicable, about any problems noted during review of personnel records Signature of Surveyor 2017 ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 78

93 Resources for Credentials Verification Primary Source Verification Primary Source Verification is documented verification by an entity that issued a credential, such as a medical school or residency program, indicating that an individual s statement of possession of a credential is true. Verification can be done by mail, fax, telephone, or electronically, provided the means by which it was accomplished is documented and measures are taken to demonstrate there was no interference in the communication by an outside party. The following sites maintain lists of schools and certifying boards that may be helpful in obtaining primary source verification. For verification from Resource Organization Web address Chiropractic schools Association of Chiropractic Colleges Dental schools American Dental Association search-dental-programs Medical schools Association of American Medical Colleges Liaison Committee on Medical Education Nursing schools American Association of Colleges of Nursing nursing-program-search Physician Assistant American Academy of Physician schools Assistants Podiatric schools American Assn of Colleges of Podiatric medicine Residency and Fellowship Accreditation Council on Graduate programs Medical Education State licensing agencies Federation of State Medical Boards American Association of Dental Boards ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 79

94 Resources for Credentials Verification Secondary Source Verification Secondary source verification is documentation of a credential obtained through a verification report from an entity (such as those listed below) that has, itself, performed the primary source verification. Information received from any of these sources must meet the same transmission and documentation requirements as outlined above for primary sources. Also valid for compliance with AAAHC Standards is primary or acceptable secondary source verification from another organization such as a hospital or medical group provided it supplies directly, without transmission or involvement by the applicant or other third party, original documents or photocopies of the verification reports it has relied upon. A statement that it has performed verification is not sufficient. Documents, diplomas, certificates or transcripts provided directly by the applicant rather than by the primary or secondary source are not acceptable. The following are a few internet resources for verification of credentials: Resource Organization American Medical Association Physician Masterfile Federation of Chiropractic Licensing Boards American Association of Dental Boards Federation of State Medical Boards American Association of Nurse Anesthetists American Board of Medical Specialties American Osteopathic Information Association American Nurses Credentialing Center Educational Commission for Foreign Medical Graduates National Commission on Certification of Physician Assistants Web address Certification_ Verification/default.aspx VerifyCertification. aspx ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 80

95 Appendices

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97 Appendix A Organization s Right of Appeal Following Denial or Revocation of Accreditation Initial Decision and Opportunity to Submit Additional Material A proposed recommendation with respect to accreditation by AAAHC is reported to the chief medical executive and the administrative head of the organization. If the proposed recommendation is to deny accreditation or revoke accreditation, such notice will include an explicit statement of the reasons for the decision and generally provide the organization with an opportunity to submit additional material to the AAAHC office within 14 calendar days of receipt of the notice. Unless otherwise indicated by AAAHC, the information provided should be limited to that available at the time of the survey and relative to the Standards identified by AAAHC as less than substantially compliant. The information that is provided will be considered by AAAHC in rendering the final accreditation decision. Final Decision Subject to Right to Appeal Any decision to deny or revoke accreditation by AAAHC will be accompanied by an explanation of the reasons for the decision and of the organization s right to a hearing before an Appeals Hearing Panel. Unless otherwise specified by AAAHC, the panel will be composed of three individuals designated by the President and CEO of AAAHC. The panel will not include: (1) any person who participated in the accreditation decision on behalf of AAAHC; (2) any person who is or ever has been a surveyor of the organization; (3) more than one director from the AAAHC Board of Directors; or (4) any person who is in direct economic competition with or has a bias with respect to the organization seeking accreditation. The organization s written request for a hearing to appeal a decision to deny or revoke accreditation must be received within ten calendar days of the date of the notification, along with a one-time nonrefundable payment of $ to defray administrative costs incurred in planning and convening the appeals hearing. If the organization fails to request such a hearing on a timely basis, or fails to include payment of $ at the time of the request, the decision becomes final. The appeal of any decision is governed by AAAHC s appeal procedures that are in effect at the time of the appeal. Hearing Before the Appeals Hearing Panel A hearing before the Appeals Hearing Panel that is requested by an organization is ordinarily held within 60 calendar days following receipt by AAAHC of its written request and the administrative payment of $ In the event that the organization is not available for an appeals hearing within 60 calendar days the organization will be deemed to have waived its right to an appeal unless AAAHC, in its sole discretion, agrees to extend the period for the appeal. Approximately 14 calendar days before the hearing, the organization is provided notice of the time and place of the hearing, and the name, professional credentials, and location of the panel members. When the decision is based on findings from an on-site survey, the organization will be provided the factual findings included in the survey report. The hearing will be held at the AAAHC office, unless otherwise agreed by the organization and the AAAHC. Panel members may be convened by conference call, and the hearing may proceed with only two of the panel members participating. At the hearing before the Appeals Hearing Panel, the organization may be accompanied by counsel, make oral presentations, offer testimony, and interview any available surveyor(s) who participated in the survey. At least 14 calendar days before any such hearing, the organization may request, in writing, the presence at the hearing of any such surveyor(s) it wishes to interview. Surveyors who are requested to participate in the hearing may be convened by conference call. If the organization makes any written submission to the Appeals Hearing Panel, the documents should be provided to AAAHC prior to the hearing. The Appeals Hearing Panel will consider all materials submitted to it on a timely basis. When the accreditation decision is based on findings from a survey, the recommendation of the Appeals Hearing Panel will be based on the organization s compliance with the AAAHC Standards effective at the time of the survey. Following the hearing before the Appeals Hearing Panel, the organization will be notified promptly of the panel s recommendation. If the panel s recommendation is to uphold the original decision to deny or revoke accreditation, the organization has the right to appeal directly to the AAAHC Board of Directors ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 81

98 Appendix A: Organization s Right of Appeal Following Denial or Revocation of Accreditation The organization s written request for appeal to the Board must be received within ten calendar days of the date of notification of the Appeals Hearing Panel s recommendation. If the Appeals Hearing Panel recommends granting accreditation, the organization will be notified of the recommendation, and the Accreditation Committee will be afforded the opportunity to consider the recommendation of the Appeals Hearing Panel at their next regularly scheduled meeting. Following this meeting, the organization will be notified promptly of the accreditation decision. If the decision to deny or revoke accreditation is not modified or reversed by the Accreditation Committee, the organization has ten calendar days from the date of such notice to appeal directly to the AAAHC Board of Directors. Appeal to the AAAHC Board of Directors The Board of Directors will consider any appeal at its first regular meeting that is scheduled at least 30 calendar days after receipt of the request for appeal. Members of the Accreditation Committee will not participate in the discussion or the vote by the Board of Directors relative to the accreditation of the organization. Similarly, any AAAHC director who has an interest in the organization, who is a direct economic competitor of the organization, who was a surveyor of the organization, or who was a member of the Appeals Hearing Panel will not participate in the discussion or the vote by the Board of Directors. The organization may submit, at least 20 calendar days prior to the Board meeting, a written response or comments for review by the Board. The Board will review any such written response and comments submitted, the survey report, and any other materials considered by the Appeals Hearing Panel, and make an accreditation decision that will be final. When the accreditation decision is based on findings from a survey, the Board s decision will be based on the organization s compliance with the AAAHC Standards in effect at the time of the survey. Exceptions with Respect to the Above Appeal Procedures AAAHC reserves the right to immediately revoke or deny accreditation before providing notice and an opportunity to submit additional materials or appeal the accreditation decision when, among other things, the organization s failure to satisfy the AAAHC Standards may result in imminent danger to the health of any individual or individuals. Under such circumstances, AAAHC shall provide subsequent notice and the opportunity to appeal. AAAHC also reserves the right to deny an organization the right to an appeal if: (1) The organization no longer satisfies the AAAHC Survey Eligibility Criteria. (2) The organization fails to notify AAAHC of a significant change (for a complete list of what constitutes significant changes, see Continuation of Accreditation Following a Significant Change on page 10). (3) Any imposition of sanctions, changes in license or qualification status, governmental investigation or proceedings, or violation of state or federal law with respect to the organizations, its officers, administrators, physicians/practitioners, or staff occurs. Conditions with Respect to the Appeal Process An appeal of an accreditation decision generally does not extend or otherwise affect the term of accreditation. If accreditation is revoked, the organization is not accredited during the appeals process. If an accredited organization seeking re-accreditation is denied, the organization generally remains accredited until the original term of the accreditation expires, which could occur during the appeals process. Any appeal conducted pursuant to these procedures requires all parties to act in good faith. An organization s failure to participate in the appeal process in good faith, including, but not limited to, the submission of falsified, incomplete, or inaccurate documents or information for any use during the appeal of an accreditation decision may result, at the discretion of the AAAHC Board of Directors, in termination of the organization s right to appeal the decision and immediate termination of the appeal. Any organization that exercises its right to an appeal is obligated to notify AAAHC immediately of any significant change as outlined in Continuation of Accreditation Following a Significant Change on page 10. No organization may exercise its right to an appeal at the same time that it applies for a new AAAHC accreditation survey. Organizations that apply for an accreditation survey should be aware that information about the basis for the previous denial or revocation will be provided to the surveyor ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 82

99 Appendix B AAAHC Timeline 1983 AAAHC adds an accreditation program for managed care organizations. American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) joins the Board as a member organization American Academy of Dental Group Practice (AADGP) joins the AAAHC Board The Mackool Eye Institute 1998 (Astoria, NY) becomes the 1000th organization accredited by AAAHC. American Association of Oral and Maxillofacial Surgeons (AAOMS) and American Academy of Cosmetic Surgery (AACS) join the Board Office-based surgery accreditation program established AAAHC is founded to offer an accreditation program for primary and surgical care organizations. Charter Board of Directors members: American College Health Association (ACHA), American Group Practice Association (now AMGA), Federated Ambulatory Surgery Association (now ASCA), Group Health Association of America (now AAHP), the Medical Group Management Association (MGMA), National Association of Community Health Centers (NACHC) 1996 Centers for Medicare & Medicaid Services (CMS) grant deemed status to AAAHC for Medicare certification of ambulatory surgery centers. This status has been continuously renewed with the current term running to American College of Obstetricians and Gynecologists (ACOG), American Society of Anesthesiologists (ASA), Society for Ambulatory Anesthesia (SAMBA) and the American Academy of Dermatology (AAD) join AAAHC. AAAHC Institute for Quality Improvement is established to help health care organizations identify, measure, and achieve QI goals. Healthcare Consultants International is established as a for-profit consulting group to aid organizations in preparing for accreditation ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 83

100 2005 American College of Gastroenterology (ACG), American Society for Gastrointestinal Endoscopy (ASGE) join the AAAHC Board AAAHC International is founded and expands AAAHC accreditation to Central and South America. CMS grants deemed status for health maintenance and preferred provider organizations participating in Medicare Advantage Accreditation Association for Hospitals/Health Systems (AAHHS) established to bring accreditation resources to smaller, rural hospitals. American Dental Association (ADA) joins the AAAHC Board. AAAHC expands its Medical Home program to include a second form of recognition: On-Site Certification AAAHC is 35 Years Strong, celebrating a continuing history of improving quality and patient in ambulatory health care. AAAHC International is re-named Acreditas Global American Gastroenterological Association (AGA) joins the AAAHC Board AAAHC launches first-in-nation Medical Home accreditation based on point-of-care review. Bureau of Primary Health Care (BPHC) awards a contract for AAAHC accreditation of federally supported health centers Rochester Surgery Center 2011 (MI) becomes the 5,000th organization accredited by AAAHC. Association of perioperative Registered Nurses (AORN) joins the AAAHC Board AAAHC Health Plan accreditation is accepted by CMS for plans participating in State and Federal Exchanges under the Patient Protection and Affordable Care Act (PPACA) The Accreditation Association (parent of AAAHC) acquires the Health Facilities Accreditation Program (HFAP) from the American Osteopathic Association (AOA) and places it under the direction of AAHHS ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 83

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103 Appendix C Members and Leadership AAAHC Member Organizations: Alphabetical by organization ASCA Foundation American Academy of Cosmetic Surgery (AACS) American Academy of Dental Group Practice (AADGP) American Academy of Dermatology (AAD) American Academy of Facial Plastic & Reconstructive Surgery (AAFPRS) American Association of Oral & Maxillofacial Surgeons (AAOMS) American College of Gastroenterology (ACG) American College Health Association (ACHA) American College of Mohs Surgery (ACMS) American Congress of Obstetricians & Gynecologists (ACOG) American Dental Association (ADA) American Gastroenterological Association (AGA) American Society of Anesthesiologists (ASA) American Society for Dermatologic Surgery Association (ASDSA) American Society for Gastrointestinal Endoscopy (ASGE) Association of perioperative Registered Nurses (AORN) Society for Ambulatory Anesthesia (SAMBA) Current Officers ( ) Meena Desai, MD, Board Chair Kenneth M. Sadler, DDS, MPA, FACD, FICD, Vice Chair Arnaldo Valedon, MD, Treasurer Ira Cheifetz, DMD, Secretary Medical Director Jack Egnatinsky, MD The Accreditation Association President and CEO Vicky Gordon, PhD (interim) Current AAAHC Board of Directors In alphabetical order Edward S. Bentley, MD, Steven Butz, MD, Bruce Cameron, MD, Frank J. Chapman, MBA, Ira Cheifetz, DMD, W. Patrick Davey, MD, MBA, Jan Davidson, MSN, RN, CPHRM, Mark S. DeFrancesco, MD, MBA, Meena Desai, MD, Robin Elwood, MD, Ann Geier, RN, MS, CNOR, CASC, Richard D. Gentile, MD, David Hamel, DDS, Joy Himmel, PsyD, PMHCNS-BC, LPC, Irving Hirsch, MD, George Hruza, MD, Sandra Jones, LHRM, CHCQM, MBA, MSM, John P. Keats, MD, CPE, Lawrence S. Kim, MD, Ross Levy, MD, W. Elwyn Lyles, MD, FACG, S. Teri McGillis, MD, Mark Mandell-Brown, MD, Kenneth M. Sadler, DDS, MPA, FACD, David M. Shapiro, MD, James Schall, DDS, Edwin W. Slade, DMD, JD, Arnaldo Valedon, MD, Mary Ann Vann, MD, Christopher J. Vesy, MD, Public Members Timothy J. Peterson, MD, Dennis Schultz, MD, ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 85

104 Members and Leadership Past Board Officers Chair: Frank Chapman, MBA, W. Patrick Davey, MD, MBA, FACP, Margaret E. Spear, MD, Karen McKellar, Jack Egnatinsky, MD, Marshall M. Baker, MS, FACMPE, Mark S. DeFrancesco, MD, MBA, Bruce N. Rogers, DDS, MBA, Raymond E. Grundman, Roy C. Grekin, MD, Francis P. DiPlacido, DMD, Gerald G. Edds, MD, C. William Hanke, MD, William H. Beeson, MD, Margaret W. Bridwell, MD, Bernard A. Kershner, Sam J.W. Romeo, MD, MBA, Frank J. Newman, MD, Carl J. Battaglia, MD, Nicholas D. Wing, MD, David J. McIntyre, MD, John R. Johnson, Wallace A. Reed, MD, John F. Rose, Jr., MD, Vice Chair: Meena Desai, MD, Frank Chapman, MBA, W. Patrick Davey, MD, MBA, FACP, Margaret E. Spear, MD, Karen McKellar, Jack Egnatinsky, MD, Marshall M. Baker, MS, FACMPE, Mark S. DeFrancesco, MD, MBA, Bruce N. Rogers, DDS, MBA, Raymond E. Grundman, Roy C. Grekin, MD, Francis P. DiPlacido, DMD, Gerald G. Edds, MD, C. William Hanke, MD, William H. Beeson, MD, Margaret W. Bridwell, MD, Bernard A. Kershner, Sam J.W. Romeo, MD, MBA, Frank J. Newman, MD, Carl J. Battaglia, MD, Joseph C. Belshe, MD, Nicholas D. Wing, MD, David J. McIntyre, MD, F. Daniel Cantrell, Wallace A. Reed, MD, Treasurer: Kenneth M. Sadler, DDS, MPA, FACD, FICD, Meena Desai, MD, Frank Chapman, MBA, W. Patrick Davey, MD, MBA, FACP, Margaret E. Spear, MD, Karen M. McKellar, Jack Egnatinsky, MD, Beverly K. Philip, MD, Raymond E. Grundman, Benjamin S. Snyder, Stanley E. Salzman, Bernard A. Kershner, Barry W. Averill, John R. Johnson, William E. Costello, Secretary: Arnaldo Valedon, MD, Kenneth M. Sadler, DDS, MPA, FACD, FICD Meena Desai, MD, Timothy Peterson, MD, Lawrence S. Kim, MD, FACG, AGAF, Margaret E. Spear, MD, Karen M. McKellar, Marshall M. Baker, MS, FACMPE, Mark S. DeFrancesco, MD, Bruce N. Rogers, DDS, MBA, Beverly K. Philip, MD, Raymond E. Grundman, Dennis Schultz, MD, Past Chief Executive Officers Stephen A. Martin, PhD, MPH, John E. Burke, PhD, Christopher A. Damon, Ronald S. Moen, Sr., ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 86

105 Members and Leadership Past Directors In alphabetical order Kenneth Ackerman, James T. Al-Hussaini, MD, Jeffrey Apfelbaum, MD, Rodney C. Armstead, MD, Barry W. Averill, Marshall M. Baker, MS, FACMPE, Richard D. Baerg, MD, Carl J. Battaglia, MD, Carol Beeler, William H. Beeson, MD, Louis Belinfante, DDS, Joseph C. Belshe, MD, Gordon Bergy, MD, W. Dore Binder, MD, Margaret W. Bridwell, MD, Aaron L. Brown, Jr., Sorin J. Brull, MD, Kimberly J. Butterwick, MD, Daniel Cantrell, Jean Chapman, MD, Lester L. Cline, Robin Collins, RN, William J. Conroy, MD, Mary Conti, MD, Gail Cooper, William E. Costello, Boyden L. Crouch, MD, Thomas Curtin, MD, Beth S. Derby, Francis P. DiPlacido, DMD, Richard L. Dolsky, MD, Gerald G. Edds, MD, Jack Egnatinsky, MD, Scott Endsley, MD, MSc, Thomas H. Faerber, MD, DDS, Robert Fenzl, MD, Alan P. Feren, MD, Robert F. Fike, MD, Forrest Flint, William W. Funderburk, MD, Louis S. Garcia, John S. Gilson, MD, Stanley R. Gold, MD, Roy C. Grekin, MD, Thomas E. Gretter, MD, Raymond E. Grundman, Steven A. Gunderson, DO, C. William Hanke, MD, Raafat S. Hannallah, MD, Dudley H. Harris, MD, Theodore R. Hatfield, MD, Paul J.M. Healey, MD, Ronald A. Hellstern, MD, John T. Henley, MD, Susan M. Hughes, MD, Jesse Jampol, MD, Charles Jerge, DDS, Thomas A. Joas, MD, John R. Johnson, Dwight E. Jones, MD, Girish P. Joshi, MD, Bernard A. Kershner, John Kingsley, MD, Scott H. Kirk, MD, M. Robert Knapp, MD, Gerard F. Koorbusch, DDS, MBA, Frank W. Kramer, MD, Donald Kwait, DDS, Melanie S. Lang, DDS, MD James E. Lees, Donald Linder, MD, William B. Lloyd, MD, Francis F. Manning, Sarah Martin, MBA, RN, CASC, David J. McIntyre, MD, Karen M. McKellar, Gregg M. Menaker, MD, James W. Merritt, MD, John W. Montgomery, Frank J. Newman, MD, Irvin O. Overton, Michael H. Owens, MD, Louie L. Patseavouras, MD, Beverly K. Philip, MD, Jerome R. Potozkin, MD, Wallace A. Reed, MD, Clifford B. Reifler, MD, MPH, Jack Richman, MD, Bruce N. Rogers, DDS, MBA, Sam J.W. Romeo, MD, MBA, John F. Rose, Jr., MD, Conrad Rosenberg, MD, ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 87

106 Members and Leadership Leonard Rubin, MD, Michael A. Safdi, MD, MPA, FACD, MACG, Stanley E. Salzman, Samuel O. Sapin, MD, Blane Schilling, MD, Dennis Schultz, MD, Benjamin S. Snyder, Margaret E. Spear, MD, J. Craig Strafford, MD, Ronald W. Strahan, MD, Christopher Strayhorn, MD, Lance A. Talmage, MD, Scott Tenner, MD, FACG, MPH, Nancy Eve Thomas, MD, Howard A. Tobin, MD, Stephen H. Troyer, DDS, Rebecca S. Twersky, MD, Seymour Weiner, MD, Ronald G. Wheeland, MD, Duane C. Whitaker, MD, / George W. Whiteside, Robert C. Williams, Douglas Williamson, MD, Thomas D. Wilson, Nicholas D. Wing, MD, ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE, INC. 88

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