The healthcare facility must consistently meet these requirements throughout the accreditation process. Unlike standards, these requirements are not scored during the on-site survey; instead, Healthcare facilities are deemed either compliant or non-compliant. If the facility fails to meet a particular requirement, it will need to rectify the issue to avoid jeopardizing its accreditation status.

Key rules and norms:

(Accreditation may be withdrawn or placed at risk of rejection if any of these items are violated)

• The facility must provide AAA with all necessary documents demonstrating full compliance with national laws and regulations relevant to the types of services it provides.
• In instances where both AAA standards and applicable laws or regulations address the same concept, the organization is required to adhere to the higher or stricter standard set by either authority.
• The facility shall ensure the validity of the documents and data provided at all stages of the accreditation process. If there is evidence that the submitted documents are proven to be inaccurate, the facility is at risk of rejection of accreditation.
• The facility is required to use AAA’s logo according to the document (R-GEN-02 requirements of use of accreditation symbol).
• The accreditation may be withdrawn or at risk of rejection if there is evidence that the facility has falsified or withheld or intentionally misled the information submitted to AAA.
• In the event of a sentinel or serious adverse event, AAA must be informed within 7 days of its occurrence by emailing healthcare@aaa-accreditation.org event’s occurrence or notification to prevent or reduce recurrence, depending on the nature of the event.
• Sentinel events are a specific category of adverse events that are entirely preventable and lead to serious harm or death of a patient. These incidents represent the most severe unexpected occurrences reported through the facility’s occurrence reporting system.
• AAA prioritizes the healthcare facility’s adherence to its national laws and regulations regarding the reporting of sentinel events. However, if these events have not yet been defined at the national level, AAA establishes specifications for the nine sentinel events to clarify what constitutes a sentinel event. This is designed to promote consistency in reporting. (Please refer back to the first two items of the key rules and norms).

 

AAA list of sentinel events:

1. Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death.
2. Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death.
3. Wrong surgical or other invasive procedure performed on a patient resulting in serious harm death.
4. Discharge or release of an infant or child to an unauthorized person.
5. Use of physical or mechanical restraint resulting in serious harm or death.
6. Medication error resulting in serious harm or death.
7. Suspected or suicide of a patient in an acute psychiatric unit or acute psychiatric ward.
8. Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death.
9. Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death.

• Any changes in the scope of services provided (e.g. adding a new service, cancelling an existing service, or increasing the volume of an existing service) must be reported at least within one month before the implementation.
• The facility is required to submit corrective action plans in case of the presence of one not met compliance element or more (standards progress report).
• The facility should be prepared to address all financial-related matters if subjected to a follow-up focused survey, as specified by AAA.
• The facility must not obstruct AAA surveyors in the performance of their duties, including refusing or hindering their access to documents and data pertinent to their responsibilities.

 

• The facility permits AAA to request and review any original or verified copies of results and reports from external evaluations conducted by publicly recognized organizations.
• The healthcare facility informs the public it serves about how to contact its management and AAA to report concerns regarding patient safety and quality of care. Notification methods may include, distributing information about AAA and posting this information on the facility’s website.
• The following email is provided to report a patient safety or quality-of-care concern to AAA: healthcare@aaa-accreditation.org

 

Service Scope Assessment:

• The facility must provide a clear and detailed description of the scope of services it provides, and it shall ensure the following;

1. The facility must offer a comprehensive range of acute care clinical services, including diagnostic, curative, and rehabilitative care.
2. Services must be available year-round, ensuring that all direct patient care services operate 24 hours a day, 7 days a week. Additionally, ancillary and support services necessary for addressing emergent, urgent, and/or emergency patient needs must also be available 24/7 (e.g., diagnostic testing, laboratory services, and operating theatres, as applicable to the type of acute care facility).
3. For specialty healthcare facility, a clearly defined set of services must be provided, such as paediatric care, ophthalmology, dental services, and psychiatry, among others.

 

Translation and interpretation services:

Translation and interpretation services shall be arranged by the healthcare facility for an accreditation survey and related activities. A qualified professionals who have no affiliation with the facility must be provided. These qualified translators and interpreters are required to uphold at least the following documents:

1. Proof of advanced education in English and the language of the host healthcare facility.
2. Evidence of translation and interpretation experience, preferably within the medical field
3. Membership(s) in professional translation and interpretation associations