Administrative Manual for Ambulatory Care Facilities

The Administrative Manual for Ambulatory Care Facilities covers every topic your free-standing ambulatory care center will need, from Patient Assessment to Performance Improvement in one easy-to-use volume. This comprehensive manual includes over 340 comprehensive policies, procedures and forms to meet Joint Commission and AAAHC standards. MCN Healthcare cross-references the policies to the current TJC and AAAHC standards in the table of contents, so you don't have to!

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Table of Contents - TJC Standards and CMS RegulationsTable of Contents - AAAHC Standards and CMS [ASC] RegulationsCopyrightDisclaimerAdmin for Ambulatory.10.changesApproval/Signature SheetIntroduction
SECTION 01 - HUMAN RESOURCES
1001 - Job Description1002 - Staff Qualifications and Competency1003 - Licensure, Certification and Registration Verification and Control Systems1004 - Background Screening1005 - Pre-Employment Physical Examination1006 - Employee Health Program1007 - New Employee Orientation1008 - New Employee General Orientation Checklist1009 - Inservice Education Program1010 - Educational Needs Assessment Form - Clinical1011 - Educational Needs Assessment Form - Nonclinical1012 - Performance Evaluations1013 - Position Description/Performance Evaluation - Ambulatory Care Services Director1014 - Performance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Services Director1015 - Annual Competency Clinical Skills Assessment - Ambulatory Care Services Director1016 - Position Description/Performance Evaluation - Ambulatory Care Services Nurse Manager1017 - Performance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Services Nurse Manager1018 - Annual Competency Clinical Skills Assessment - Ambulatory Care Services Nurse Manager1019 - Position Description/Performance Evaluation - Ambulatory Care Services Secretary1020 - Performance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Services Secretary1021 - Annual Competency Skills Assessment - Ambulatory Care Services Secretary1022 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol
SECTION 04 - LEADERSHIP
4001 - Leadership Structure4002 - Facility Leadership Structure Chart (Example)4003 - Outpatient Surgery Organizational Chart (Example)4004 - Your Facilitys Organizational Chart4005 - Planning Process for Ambulatory Care Services4006 - Plan for the Provision of Patient Care and Services4007 - Scope of Services4008 - Position Description/Performance Evaluation - Chief Executive Officer, Ambulatory Care Services4009 - Annual Competency Skills Assessment - Chief Executive Officer, Ambulatory Care Services4010 - Staff Recruitment, Retention and Education4011 - Position Description/Performance Evaluation - Nurse Executive4012 - Authority in Absence of Administration4013 - Orientation of Governing Body, Senior Management, Medical Staff Leaders4014 - Mission and Vision Statements4015 - Your Organization’s Mission Statement4016 - Your Organization’s Vision Statement4017 - Organizational Strategic Plan4018 - Organizational Policies - Corporate Level4019 - Communication Process - Staff, Patients and Community4020 - Your Organization’s Patient Care Brochure4021 - Patient Satisfaction Questionnaire4022 - Patient Satisfaction Questionnaire - Physical Therapy Services4023 - Code of Conduct - Sample4024 - Culture of Safety and Quality4025 - Disruptive and Inappropriate Behavior4026 - Disruptive Staff Member Incident Report Form4027 - Incident Reporting Staff Questionnaire4028 - Examples of Survey Tools to Survey a Culture of Safety and Quality4029 - Performance Improvement Committee 20__ Annual Program and Leadership Evaluation4030 - Departmental Staff Meetings4031 - Quarterly Report to Governing Body - Personnel Evaluations4032 - Laws, Rules and Regulations4033 - Corporate Compliance Plan4034 - Title VI of the Civil Rights Act of 1964, and Section 504 of the Rehabilitation Act of 19734035 - Identity Theft Prevention Program Overview4036 - Stark Policy4037 - Social Media - Guidelines for Use4038 - Social Media for Organizational Purposes4039 - Budget Process4040 - Purchases, Capital Expenditures - Equipment, Renovation, Supplies4041 - Space, Equipment and Resources4042 - Grounds Safety4043 - Facility Program, Service, Site, Department Leadership4044 - Example of Medical Staff Rules and Regulations Wording4045 - Development of Departmental Policies and Procedures4046 - Development of Interdepartmental Policies and Procedures4047 - Policy and Procedure Conflicts4048 - Assessment Policies4049 - Interdisciplinary Computerized Planning for Patient Care4050 - Storage and Procurement of Blood4051 - Code of Ethics4052 - Bioethics Committee Consultation4053 - Conflict of Interest4054 - Conflict of Interest Disclosure Letter (Sample)4055 - Staff Member Conflict of Interest - Annual Acknowledgement Form4056 - Financial Incentives/Clinical Decision Making4057 - Physician-Owned Facilities Notification Statement Policy4058 - Decisions Regarding Coverage of Care4059 - Contract Services4060 - Oversight of Contractual Agreements4061 - Outside Reference Laboratory Authorization4062 - Use of Outside Reference Clinical Laboratory Services - Clinical Laboratory4063 - Use of Outside Reference Clinical Laboratory Services - Pathology4064 - Use of Outside Imaging Services4065 - Marketing Practices4066 - Billing Practices4067 - Resolution of Conflict Related to Patient Billing4068 - Utilization Management4069 - HMO Treatment/Authorization Consent Form4070 - Community Needs Assessment4071 - Community Needs Assessment Survey Tool/Questionnaire4072 - Levels of Care4073 - Patient Safety Plan4074 - Patient Safety Program Checklist4075 - Sentinel Event4076 - Conducting Root Cause Analysis4077 - Development and Review of Clinical Guidelines4078 - Clinical Practice Guideline Development and Implementation4079 - Clinical Practice Guidelines Selection Criteria4080 - Clinical Practice Guideline Implementation Methodology4081 - Staff Rights and Ethical Dilemmas in Patient Care
SECTION 05 - MEDICATION MANAGEMENT
5001 - Pharmacy Essentials of Patient Information for Medication Dispensing and Administration5002 - Medication Patient Information and Reconciliation - Outpatient5003 - Medication Patient Information and Reconciliation Form5004 - High Alert Medication Management5005 - Your Facility's List of High-Risk/High Alert Medications5006 - Look-Alike, Sound-Alike Medication Management5007 - Drug Availability5008 - Procurement of Medications5009 - Monitoring Effects of Medications on Patients5010 - Drug Shortage Mitigation Plan - Facilitywide5011 - Drug Inventory Control5012 - Automated Dispensing Machines - Access to5013 - Automated Dispensing Machines - Removing Medications5014 - Controlled Drug Management5015 - Automated Dispensing Machines - Controlled Substances5016 - Monitoring of Drug Outdates5017 - Unusable and Outdated Drugs5018 - Drug Recalls5019 - Routine Vaccine Storage and Handling Plan5020 - Emergency Medications5021 - Emergency Medications List5022 - Emergency Crash Carts5023 - Emergency Crash Cart Security and Accountability5024 - Alternative Medication Administration5025 - Prescribing/Ordering - General Practices5026 - Telephone, Verbal and Written Orders for Medication5027 - Sample Medications - Facility/Physician's Offices5028 - Prescription Pad Security5029 - Pediatric Dosing - General Guidelines5030 - Standing Orders5031 - Range Orders for Medications5032 - Influenza and Pneumococcal Vaccine Standing Orders5033 - Medication Orders (Pharmacy)5034 - Pharmacist Order Verification5035 - When the Facility Does Not Operate a Pharmacy5036 - Medication Administration - Facilitywide5037 - Patient Immunization Record5038 - Medication and Solution Administration - Invasive Procedures5039 - Multiple Dose Vials (MDVs) - Use of5040 - Oral and Rectal Contrast Media Administration5041 - Safe Medication Practices5042 - Decreasing Medication Errors5043 - Medication Errors5044 - Medication Error Analysis Tool5045 - Medication Inadvertent Incident Report Form5046 - Performance Improvement Analysis - Medication Inadvertent Incident Form5047 - Adverse Drug Reaction Definition and Process5048 - Adverse Drug Reaction Reporting Form (Internal)5049 - Medication Management Program
SECTION 06 - PERFORMANCE IMPROVEMENT
6001 - Organizational Performance Improvement Plan6002 - Performance Improvement Monitoring and Evaluation Plan (blank)6003 - Performance Improvement Trending Sheet (blank)6004 - Performance Improvement Outcome Evaluation (blank)6005 - Performance Improvement Volume Measures/Statistics (blank)6006 - Analysis of Risk Potential Form - Blank6007 - Analysis of Risk Potential Form - Sample6008 - Failure Mode and Effects Analysis Form6009 - Occurrence Reporting and Processing (Incident Reports)6010 - Incident Report Form (Internal)6011 - Performance Improvement Incident Analysis Form6012 - Incident Report Trending Sheet6013 - Risk Management Follow-Up Form6014 - Risk Management Monthly Safety Committee Report Form6015 - Patient Satisfaction Questionnaire6016 - Pharmacy Department PI Trending Sheet6017 - Pharmacy Department PI Volume Measures/Statistics6018 - Imaging Services PI Monitoring and Evaluation Plan6019 - Imaging Services PI Trending Sheet6020 - Imaging Services PI Outcome Evaluation6021 - Imaging Services PI Volume Measures/Statistics6022 - Department of Imaging Services/Radiology - Patient Satisfaction Questionnaire6023 - Engineering PI Monitoring and Evaluation Plan6024 - Engineering PI Trending Sheet6025 - Engineering PI Outcome Evaluation6026 - Engineering PI Volume Measures/Statistics6027 - Outpatient Surgery/Ambulatory Care PI Monitoring and Evaluation Plan6028 - Outpatient Surgery/Ambulatory Care PI Trending Sheet6029 - Management of the Patient in the Ambulatory Surgical Setting Worksheet6030 - Licensed Independent Practitioner Quality Monitoring Review - Moderate/Deep Sedation6031 - Anesthesia Generic Screens Form6032 - Ambulatory Surgery - Outpatient Transferred to Acute Care Form6033 - GI Lab PI Monitoring and Evaluation Plan6034 - GI Lab PI Trending Sheet6035 - GI Lab PI Outcome Evaluation6036 - GI Lab PI Volume Measures/Statistics6037 - Urgent Care - Nursing Staff Quality Assessment Review - Documentation6038 - Urgent Care - Nursing Staff Quality Assessment Review - Elopement6039 - Urgent Care - Nursing Staff Quality Assessment Review - Against Medical Advice (AMA)6040 - Urgent Care - Nursing Staff Quality Assessment Review - Left Without Being Seen (LWBS)6041 - Urgent Care - Medical Staff Quality Assessment Review - Lacerations6042 - Urgent Care - Medical Staff Quality Assessment Review - Abdominal Pain6043 - Urgent Care - Medical Staff Quality Assessment Review - Orthopedic Injury6044 - Urgent Care - Medical Staff Quality Assessment Review - Chest Pain6045 - Urgent Care - Medical Staff Quality Assessment Review - Pediatric Fever6046 - Urgent Care - Medical Staff Quality Assessment Review - Pediatric Gastroenteritis6047 - Urgent Care - Medical Staff Quality Assessment Review - Eye Pain6048 - Urgent Care - Medical Staff Quality Assessment Review - Code Blue6049 - Urgent Care - Medical Staff Quality Assessment Review - Generic Medical Record Review6050 - Urgent Care - Medical Staff Quality Assessment Review - Return to Clinic Within 72 Hours6051 - Medical Staff Peer Review Program6052 - Committee Activity Summary Form6053 - Practitioner Quality Monitoring Profile6054 - Audit Review Summary Form6055 - Peer Review Form6056 - Office/Clinic Evaluation Form6057 - Code Evaluation6058 - Code Blue Quality Review Worksheet
SECTION 07 - PROVISION OF CARE, TREATMENT AND SERVICES
7001 - Patient Identification for Clinical Care and Treatment7002 - The Entry Into Care7003 - Triage7004 - Emergency Care7005 - Patient Assessment7006 - Documentation of Patient Allergies7007 - Patient Problem List7008 - Pain Assessment, Reassessment and Management7009 - Follow-Up Assessment7010 - High-Risk Call Back Questionnaire7011 - Ambulatory Surgical Care Unit - Patient Phone Questionnaire7012 - GI Laboratory - Patient Phone Questionnaire7013 - Rehabilitation Services7014 - Functional Assessment/Evaluation - Rehabilitation Services7015 - Critical Results of Tests and Diagnostic Procedures - Reporting of7016 - Follow-Up of Abnormal Results on Diagnostic Tests7017 - "Hand-Off" Communication7018 - Invasive Procedure Site Identification (Outside of the OR)7019 - Obtaining Blood and Blood Components7020 - Blood/Blood Components - Transfusion7021 - Blood/Blood Components - Transfusion Reactions7022 - Nutritional Requirements - Patient7023 - Restraint Use7024 - Immobilization Devices - Use of7025 - Therapeutic Phlebotomy7026 - Education of Patient and Family7027 - Patient Education - Medical Equipment7028 - Patient Education - Use of Medications7029 - Sample Patient and Family Education Form7030 - Discharge Planning7031 - Instructions for Home Care Form7032 - Transfer to a Higher Level of Care Facility7033 - Follow-Up Care for Patients Being Discharged Home7034 - Home Health Referral7035 - Referrals for Infusion Therapy7036 - Contracted Educational Programs7037 - Community Resources List for Patients and Families
SECTION 10 - WAIVED TESTING