Are You Ready for the New AAAHC Standards?

Are you ready for the new AAAHC standards? The Accreditation Association for Ambulatory Health Care (AAAHC) handbook has been updated with an expected implementation date of November 1, 2020. The new standards include more concise language, more consistency, less repetition and of course, new standards on current best practices and regulatory requirements. Is your facility fully compliant? Do you have a consultant pharmacist on your team to help you?

Although some of the changes being made are for the sake of clarity and to reduce redundancy, there are substantive changes that will go into effect with this new version. Do you have a system in place to ensure all items are compliant? How about pharmaceutical services? Do you have a consultant pharmacist who understands the standards and can give you proper guidance to ensure survey success? Now is the time to get ahead of the curve and prepare.

Patient safety is an ongoing effort that requires constant vigilance, research and quality assurance and improvement. When it comes to medication management, AAAHC made a few changes that we believe will further enhance safety but will require additional expertise and preparation on behalf of the facilities.

So, what are the main changes when it comes to pharmaceutical services (Chapter 11)?

The medication inventory is monitored to track the presence or absence of high-alert medications and medications with confused drug names.
Nationally recognized guidelines for vaccine storage and handling are followed.

The good news for OctariusRx clients is that we have been advocating both of these items for years and if you’ve followed our guidance, you are already compliant. If you are unsure or if you are not one of our clients, please contact us so we can review these areas and help you become fully compliant as soon as possible.

Let’s look at each one of these standards, what’s required and what we recommend:

High-alert medications and medications with confused drug names:

Requirements:

A written policy describes the monitoring process and responsibility(ies) for its implementation.
Documentation demonstrates that relevant staff have been trained on the policy.
Monitoring activities are documented.

Standards:

Procedures are in place to prevent errors from high-alert medications.
Procedures are in place to prevent errors from medications with confused drug names.

Elements of Compliance (both standards):

A list of high-alert medications currently present in the facility is maintained.
Processes are in place to prevent errors from administration of these medications, in accordance with nationally recognized guidelines.

In a previous post “Managing High-Alert/Hazardous and Look-Alike-Sound-Alike Medications in Ambulatory Care Settings”, I provided additional tips on best practices. Here are some of the highlights:

Develop your own list based on unique utilization patterns and internal data about medication errors and sentinel events.
Collaborate with your pharmacy consultant to help develop your list.
Review National Institute for Occupational Safety and Health (NIOSH) resources to help develop a unique list of high-alert and hazardous medications.
Segregate medications in different bins or locations.
Distinguish medications by using “tall man lettering”, i.e. upper-case letters.
Sticker identification to identify the high alert or hazardous medications on your organization’s list.

Vaccine Storage:

Guidelines adopted by the governing body.
Written P&Ps for routine storage and handling.
Written P&Ps for storage, handling and transport in case of emergency.
Documentation of training of relevant staff.
Vaccine storage unit is equipped with a temperature monitoring device per adopted guidelines.
Staff knowledge of procedures if vaccines are exposed to a temperature excursion.

In a previous post “Tips from a Consultant Pharmacist: How to Properly Store Vaccines”, I provided guidance on best practices. This includes following guidance from the Centers for Disease Control and Prevention (CDC), which includes the following tips:

CDC Recommended Storage

Carefully select and use the appropriate vaccine storage units to store vaccines.
Have a properly calibrated thermometer or temperature recording device inside each storage compartment. We recommend a traceable thermometer.
Evaluate your cold chain procedures to ensure vaccine storage and handling guidelines are being followed. Store vaccines at the ideal temperature of 40° F.
Upon delivery, inspect vaccines; monitor refrigerator and freezer temperatures to ensure cold chain storage was maintained all along.
Rotate vaccine stock so that the oldest vaccines are used first.
Should errors in vaccine storage and administration occur, take corrective action immediately to prevent them from happening again — and notify public health authorities.

CDC Vaccine Storage Do’s:

Do make sure the refrigerator door is closed!
Do leave 2 to 3 inches between vaccine containers and refrigerator walls.
Do post “Do Not Unplug” signs on the refrigerator and near the electrical outlet.

CDC Vaccine Storage Don’ts:

Don’t use a dormitory-style refrigerator.
Don’t use the top shelf for vaccine storage.
Don’t allow food or beverages in the refrigerator.
Don’t store vaccines on door shelves or on the floor of the refrigerator.

Hopefully, this list gets you on your way to achieving full compliance, and equally importantly, improving practices that ultimately improve patient safety and outcomes. Trying to keep up with all the changes can feel like a daunting task, but it can be done successfully. Enlist the help of experts when necessary. At OctariusRx, we are relentlessly focused on patient safety. If you have questions or want a free consultation to point you in the right direction, don’t hesitate to reach out.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.