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, AAAHC standardsCopyrightDisclaimerApproval/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 - Organizational Leadership Structure Chart (Example)4003 - Your Facility's Organizational Chart4004 - Plan for the Provision of Patient Care and Services4005 - Scope of Services4006 - Position Description/Performance Evaluation - Chief Executive Officer, Ambulatory Care Services4007 - Annual Competency Skills Assessment - Chief Executive Officer, Ambulatory Care Services4008 - Staff Recruitment, Retention and Education4009 - Position Description/Performance Evaluation - Nurse Executive4010 - Authority in Absence of Administration4011 - Orientation of Governing Body, Senior Management, Medical Staff Leaders4012 - Mission and Vision Statements4013 - Your Organization's Mission Statement4014 - Your Organization's Vision Statement4015 - Organizational Strategic Plan4016 - Organizational Policies - Corporate Level4017 - Communication Process4018 - Your Organization's Patient Care Brochure4019 - Patient Satisfaction Questionnaire4020 - Physical Therapy Services Patient Questionnaire4021 - Code of Conduct4022 - Culture of Safety and Quality4023 - Disruptive and Inappropriate Behavior4024 - Disruptive Staff Member Incident Report Form4025 - Incident Reporting Staff Questionnaire4026 - Examples of Survey Tools to Survey a Culture of Safety and Quality4027 - Your Organization's Survey of a Culture of Safety and Quality4028 - Performance Improvement Committee 20__ Annual Program and Leadership Evaluation4029 - Departmental Staff Meetings4030 - Quarterly Report to Governing Body - Personnel Evaluations4031 - Laws, Rules and Regulations4032 - Corporate Compliance Plan4033 - Title VI of the Civil Rights Act of 1964, and Section 504 of the Rehabilitation Act of 19734034 - Identity Theft Prevention Program Overview4035 - Stark Policy4036 - Guidelines for the Use of Social Media4037 - Use of Social Media for Organizational Purposes4038 - Budget Process4039 - Purchases, Capital Expenditures - Equipment, Renovation, Supplies4040 - Space, Equipment and Resources4041 - Grounds Safety4042 - Facility Program, Service, Site, Department Leadership4043 - Example of Medical Staff Rules and Regulations Wording4044 - Development of Departmental Policies and Procedures4045 - Development of Interdepartmental Policies and Procedures4046 - Policy and Procedure Conflicts4047 - Assessment Policies4048 - Interdisciplinary Computerized Planning for Patient Care4049 - Storage and Procedurement of Blood4050 - Code of Ethics4051 - Bioethics Committee Consultation4052 - Conflict of Interest4053 - Conflict of Interest Disclosure Letter (Sample)4054 - Staff Member Conflict of Interest - Annual Acknowledgement Form4055 - Financial Incentives/Clinical Decision Making4056 - Physician-Owned Facilities Notification Statement Policy4057 - Decisions Regarding Coverage of Care4058 - Contract Services4059 - Oversight of Contractual Agreements4060 - Outside Reference Laboratory Authorization4061 - Use of Outside Reference Clinical Laboratory Services - Clinical Laboratory4062 - Use of Outside Reference Clinical Laboratory Services - Pathology4063 - Use of Outside Imaging Services4064 - Marketing Practices4065 - Billing Practices4066 - Resolution of Conflict Related to Patient Billing4067 - Utilization Management4068 - HMO Treatment/Authorization Consent Form4069 - Community Needs Assessment4070 - Community Needs Assessment Survey Tool/Questionnaire4071 - Levels of Care4072 - Patient Safety Plan4073 - Patient Safety Program Checklist4074 - Sentinel Event4075 - Conducting Root Cause Analysis4076 - Development and Review of Clinical Guidelines4077 - Clinical Practice Guideline Development and Implementation4078 - Clinical Practice Guidelines Selection Criteria4079 - Clinical Practice Guideline Implementation Methodology4080 - Staff Rights and Ethical Dilemmas in Patient Care
SECTION 05 - MEDICATION MANAGEMENT
5001 - Pharmacy Essentials of Patient Information for Medication Dispensing and Administration5002 - Patient Medication Information/Reconciliation - Outpatient5003 - Patient Medication Information/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 - Managing Drug Shortages in Emergency and Non-Emergent Situations5011 - Drug Inventory Control5012 - Automated Dispensing Machines - Access to5013 - Controlled Drug Management5014 - Automated Dispensing Machines - Controlled Substances5015 - Monitoring of Drug Outdates5016 - Unusable and Outdated Drugs5017 - Drug Recalls5018 - Routine Vaccine Storage and Handling Plan5019 - Emergency Medications5020 - Emergency Medications List5021 - Emergency Crash Carts5022 - Emergency Crash Cart Security and Accountability5023 - Alternative Medication Administration5024 - Prescribing/Ordering - General Practices5025 - Telephone, Verbal and Written Orders for Medication5026 - Pediatric Dosing - General Guidelines5027 - Standing Orders5028 - Range Orders for Medications5029 - Influenza and Pneumococcal Vaccine Standing Orders5030 - Medication Orders (Pharmacy)5031 - Pharmacist Order Verification5032 - When the Facility Does Not Operate a Pharmacy5033 - Medication Administration5034 - Patient Immunization Record5035 - Medication and Solution Administration - Invasive Procedures5036 - Use of Multiple Dose Vials (MDVs)5037 - Oral and Rectal Contrast Media Administration5038 - Safe Medication Practices5039 - Decreasing Medication Errors5040 - Medication Errors5041 - Medication Error Analysis Tool5042 - Medication Inadvertent Incident Report Form5043 - Performance Improvement Analysis - Medication Inadvertent Incident Form5044 - Adverse Drug Reaction Definition and Process5045 - Adverse Drug Reaction Reporting Form (Internal)5046 - Medication Management Program5047 - Sample Medications - Facility/Physician's Offices5048 - Prescription Pad Security
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 - Occurrence Report Form (Incident Report)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/Radiology PI Monitoring and Evaluation Plan6019 - Imaging/Radiology PI Trending Sheet6020 - Imaging/Radiology PI Outcome Evaluation6021 - Imaging/Radiology 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 Laboratory PI Monitoring and Evaluation Plan6034 - GI Laboratory PI Trending Sheet6035 - GI Laboratory PI Outcome Evaluation6036 - GI Laboratory 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
SECTION 10 - WAIVED TESTING