Western Kentucky University

WKUHS AAAHC Accreditation : Governance

I.D. Chapter Evidence Notes

2

Subchapter 1 -General Requirements

 

 

2.A

Governance

 Governing Body

KRS164.350 & 164.360 explain the general powers & duties of state university board of regents.

2.A.1

Governance

Governing Body

BOR Bylaws 

2.B

 Governance

Governing Body 

 

 2.C

Governance 

Governing Body  

 

2.C.1

Governance 

Governing Body 

WKUHS

 

2.C.2

Governance 

Governing Body

Staff

 Staff are credentialed and privileged based on their abilities, education and job requirements.

2.C.3

 Governance

Governing Body 

 WKUHS Org Chart

 

2.C.4-5

 Governance

Governing Body

University Policies

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

2.C.6

 Governance

Governing Body 

Care of Minor Patients

 WKUHS has procedures in place to obtain consent to care for underage patients.

2.C.7

Governance

 Governing Body

Quality of Care

See sections on Quality of Care and Quality Management & Improvement. 

2.C.8

 Governance

Governing Body

Legal matters are handled by university counsel. 

2.C.9

 Governance

Governing Body

 Meeting minutes are made available to staff.

2.C.10

Governance

Governing Body

 

2.C.11

Governance

 Governing Body

Patient rights and Responsibilities

 

2.C.12

Governance

Governing Body

 WKUHS maintains personal service contracts.

2.C.12.a

 Governance

Governing Body

See 2.C.12 

2.C.12.b

 Governance

Governing Body

See 2.C.12

 

2.C.12.c

 

Governance

 Governing Body

See 2.C.12

2.C.12.d

 Governance

Governing Body

See 2.C.12

2.C.12.e

Governance

Governing Body

After Hours Care

Information listed on doors, website and phone messages. 

2.C.12.f

Governance

Governing Body

WKUHS does not accept Medicare or Medicaid. 

2.C.12.g

 Governance

Governing Body

See 2.C.12

2.C.13

 

Governance

Governing Body

 

2.C.14

 Governance

Governing Body

University Policies

See 2.C.4-5 

2.C.15

 Governance

Governing Body

WKUHS

 Marketing materials are updated on a regular basis and are as accurate as possible.

2.C.16

 Governance

Governing Body

Risk Management Plan

 

 2.C.17

 Governance

Governing Body

See 2.C.4-5

2.C.18

Governance

Governing Body

Infection Prevention

 

2.D

Governance

Governing Body

WKUHS will contact AAAHC when events occur that will impact our ability to provide services.

 2.E

Governance 

Governing Body 

 

2.F

Governance

Governing Body

The Governing Body holds meetings, maintains meeting minutes and documentation as required by applicable AAAHC standards. 

2.G

Governance

 Governing Body

See 2.F 

2.G.1-9

Governance

Governing Body

See 2.F

2.H

Governance

Governing Body

 

 2

 Subchapter 2- Credentialing & Privileging

 

 

2.A 

Governance

Provider:Credential/Privilege 

Ancillary:Credential/Privilege

Each medical employee undergoes a credential verification and privileging process. 

 2.B

 Governance

Provider:Credential/Privilege

See 2.A 

 2.B.1

Governance

Provider:Credential/Privilege 

See 2.A 

 2.B.2

Governance

 Provider:Credential/Privilege

See 2.A 

 2.B.3

Governance

Provider:Credential/Privilege 

 See 2.A

 2.B.3.a

Governance

 Provider:Credential/Privilege

 See 2.A

 2.B.3.b

Governance

Provider:Credential/Privilege 

 See 2.A

 2.B.3.c

Governance

Provider:Credential/Privilege 

 See 2.A

 2.B.3.d

Governance

 Provider:Credential/Privilege

 See 2.A

2.B.3.e 

Governance

 Provider:Credential/Privilege

See 2.A 

2.B.3.f 

Governance

 Provider:Credential/Privilege

 See 2.A

 2.B.3.g

Governance

 Provider:Credential/Privilege

See 2.A 

.i

 Governance

Provider:Credential/Privilege 

 See 2.A

.ii

Governance

Provider:Credential/Privilege 

See 2.A 

.iii 

Governance

Provider:Credential/Privilege 

 See 2.A

.iv 

Governance

Provider:Credential/Privilege 

 See 2.A

.v

Governance

Provider:Credential/Privilege 

See 2.A 

.vi

Governance

 Provider:Credential/Privilege

 See 2.A

.vii

Governance

Provider:Credential/Privilege 

See 2.A 

.viii

Governance

 Provider:Credential/Privilege

See 2.A 

.ix

Governance

Provider:Credential/Privilege 

 See 2.A

.x

Governance

 Provider:Credential/Privilege

 See 2.A

 2.B.4

Governance

Provider:Credential/Privilege 

WKUHS uses primary source verification. 

2.B.5 

Governance

Provider:Credential/Privilege 

See 2.A 

 2.B.6

Governance

 Provider:Credential/Privilege

See 2.A 

2.B.7 

Governance

Provider:Credential/Privilege 

See 2.A 

 2.C

Governance

Provider:Credential/Privilege 

 See 2.A

 2.D

Governance

Provider:Credential/Privilege 

See 2.A 

2.E 

Governance

 Provider:Credential/Privilege

See 2.A 

 2.F

Governance

Provider:Credential/Privilege 

See 2.A 

2

 

 Subchapter 3- Peer Review

 

 

 2.A

Governance

Peer Review 

 

 2.B

Governance

Peer Review

WKUHS's Peer Review program is under the direction of the Medical Director.

 2.B.1

Governance

Peer Review

 

2.C 

Governance

Peer Review

 

 2.D

Governance

Peer Review

 

2.E 

Governance

Peer Review

 

2.F 

Governance

Peer Review

 

 2.G

Governance

Provider: Credential/Privilege

 

 2.H

Governance

Peer Review

WKUHS provides access to educational articles and information via internet access,  CME/CEU's,conferences and trainings. 

2.H.1

Governance

Peer Review

 See 2.H

2.H.2

Governance

Peer Review

See 2.H 

2.I

Governance

Provider: Credential/Privilege

Ancillary: Credential/Privilege

The Medical Director and Clinical  Nurse Manager maintain certification and licensure files for clinical staff to ensure that credentials are up to date.

 Last Modified 4/7/14