Western Kentucky University

WKUHS AAAHC Accreditation : Administration

I.D. Chapter Evidence Notes

3.A

Administration

 

 

3.A.1 

Administration

Governing Body 

Policies are enforced through delegation & employee/supervisor relationships. 

3.A.2

Administration 

Governing Body 

 

 3.A.3

Administration

 Governing Body

 In conjunction with EHS and other university departments, WKUHS works to ensure compliance with applicable laws and regulations.

3.A.4

Administration

Governing Body 

 

3.A.5

 Administration

University Finance Policies

Financial documentation and reports are handled by WKUHS's Office Coordinator and Assistant Director for Business Operations. 

3.A.5.a

Administration

 

See 3.A.5

3.A.5.b

Administration

 

See 3.A.5

3.A.5.c

Administration

 

See 3.A.5

3.A.5.d

Administration

 

See 3.A.5

3.A.6 

Administration

 Governing Body

 

3.A.7 

Administration

University Finance Policies 

WKUHS follows university purchasing policies. 

3.A.8 

Administration

Governing Body

WKUHS Org Chart 

Health Services is a function of the University's Finance and Administration Division. 

3.A.9 

Administration

 Records Management 

WKU follows the Ky. State University Model Schedule for record management. 

3.A.10 

Administration

Governing Body 

 

3.A.11 

Administration

Clinical Records

Network Security 

WKUHS maintains an electronic health records system that allows us to collect and report data as necessary to meet the needs of our organization. Staff are expected to respect the IT resources used to perform these activities.

3.A.12 

Administration

Governing Body 

 

3.B 

Administration

University Policies

Personnel Files

WKUHS follows university policies in addition to maintaining appropriate internal policies and procedures. 

3.B.1 

Administration

WKUHS Org Chart 

See 3.B 

 3.B.2

Administration

Provider:Credential/Privilege 

See 3.B

3.B.3

Administration

 University Policies

New Employee Orientation 

New employees receive training from WKUHS & Human Resources.

 3.B.3.a

 Administration

New Employee Orientation

See 3.B.3

3.B.3.b

Administration

New Employee Orientation 

See 3.B.3

3.B.4

Administration

 

Employee evaluations are performed annually with a review of job descriptions.

3.B.5

Administration

 

 See 3.B

 3.B.6

Administration

University Policies

Human Resources periodically reviews compensation for all departments and at the request of the supervisor.

 3.B.7

 Administration

University Policies

New Employee Orientation

 See 3.B

3.B.8

Administration

University Policies 

See 3.B

 3.C

Administration

B.B.P. Exposure Control

 

 WKUHS maintains programs for infection prevention and employee safety as required by OSHA regulations with consideration of recommendations from CDC and other national health care quality organizations.

 3.C.1

 Administration

B.B.P. Exposure Control

See 3.C 

 3.C.2

 Administration

B.B.P. Exposure Control

 See 3.C

3.C.3 

Administration 

B.B.P. Exposure Control 

New Employee Orientation

 See 3.C

3.C.4 

Administration

B.B.P. Exposure Control

See 3.C & D

3.C.4.a

Administration

B.B.P. Exposure Control

See 3.C & D

3.C.4.b

Administration

B.B.P. Exposure Control

See 3.C & D

3.C.4.c

Administration

B.B.P. Exposure Control

See 3.C & D

3.C.4.d

Administration

B.B.P. Exposure Control

See 3.C & D

3.D

 Administration

B.B.P. Exposure Control

Infection Prevention

Safety Handbook

Employee safety education and training is done in conjunction with university departments including Human Resources, Environmental Health & Safety and others as required by law.

See 3.C

3.D.1 

 Administration

Infection Prevention 

See 3.E 

3.D.2 

 Administration

Infection Prevention 

See 3.E 

3.D.3 

 Administration

Infection Prevention 

See 3.E 

3.E

Administration 

Safety Handbook 

See 3.E 

3.F

Administration 

 

WKU Human Resources maintains the university's Worker's Compensation program. 

3.G 

 Administration

 

Patients are encouraged to take our satisfaction survey. Aggregate survey results and outlier responses are reported to the Executive Director and reviewed by the appropriate committees.

3.H

Administration 

Univerity Policies 

 WKUHS follows financial aid, payroll and other applicable policies and processes for employing students and allowing postgraduate trainees to shadow our providers.

 Last Modified 1/31/14