WKUHS AAAHC Accreditation : Surgical & Related Services

10 

Subchapter 1 -General Requirement 

10.A 

Surgical and Related Services 

Cleaning and Disinfecting

Provider:Credential/Privilege

 Procedures performed at WKUHS are done by qualified, credentialed providers in a safe and sanitary environment.

 10.B

 Surgical and Related Services 

 Only minor procedures are performed at WKUHS ie: suture removal. These services are provided by credentialed providers under direction of the medical director.

 10.C

Surgical and Related Services 

Provider:Credential/Privilege

 See 10.A

 10.C.1

Surgical and Related Services 

Provider:Credential/Privilege

 See 10.A

10.C.2

Surgical and Related Services 

Provider:Credential/Privilege

 See 10.A

10.D

Health histories are updated at each visit as appropriate. WKUHS only performs minor procedures and does not use general anesthesia.

10.E

 10.F

This item is not applicable.

10.G 

 Consent forms are obtained prior to performing procedures.

 10.H

10.I 

 Procedure rooms are equipped for minor procedures as performed by WKUHS providers.

 10.J

 All WKUHS staff members receive CPR training.

 10.J.1

This item is not applicable

A provider is always in the facility with patients during normal operating hours.

Lab Tests-General Information

 The WKUHS lab is CLIA certified.

 All procedure documentation is added to the EHR.

Infection Prevention

Instrument Sterilization

This item is not applicable.

Policies and processes are in place to reduce chances for infection during procedures.

Hand Hygiene

 Patient permission is received before a non-WKUHS clinical staff (including visiting health care trained students) or visitor is asked to be in the room. Non-WKUHS clinical staff (excluding police only when neccessary) are not allowed in a procedure room while  a patient is being seen.

Infection Prevention

 Environmental surveillance is done on a monthly basis to catch issues as they arise.

Infection Prevention

 See 10.N.6

Infection Prevention

This item is not applicable.

Blood stained  PPE used by staff and/or coverings used by patients are appropriately disposed.

This item is not applicable.

 Cautery is not used at WKUHS.

Infection Prevention

Instrument Sterilization

WKUHS maintains properly sterilized instruments. 

Instrument Sterilization

See 10.O 

Instrument Sterilization

See 10.O

This item is not applicable.

This item is not applicable.

Environmental Health & Safety

An alternate source of power is available for essential equipment in the event of power outages. Periodic checks are performed by EHS. 

Medical Equipment Testing

All medical equipment is tested on an annual basis. 

Informed Consent

See 10.G 

Time Out Procedure

Time Out Procedure

This item is not applicable.

This item is not applicable.

This item is not applicable.

Care of Minor Patients

 Only appropriately trained and credentialed providers perform minor procedures on younger patients. WKUHS also maintains child sized items in the event of an emergency.