AAAHC:Admin

Rights of Patients
Governance
Administration
Quality of Care Provided
Quality Management Improvement
Clinical Records and Health Information
Infection Prevention and Control and Safety
Facilities and Environment
Anesthesia Services
Surgical & Related Services
Pharmaceutical Services
Pathology & Medical Laboratory Services
Diagnostic & Other Imaging Services
Other Professional & Technical Services
Health Education and Health Promotion

I.D.	Chapter	Evidence	Notes
3.A	Administration
3.A.1	Administration	Governing Body	Policies are enforced through delegation & employee/supervisor relationships.
3.A.2	Administration	Governing Body
3.A.3	Administration	Governing Body	WKUHS incorporates findings from QI studies, Patient Satisfaction surveys, Surveillance and orther monitoring activities when developing strategic plans, goals and objectives.
3.A.4	Administration	Governing Body	In conjunction with EHS and other university departments, WKUHS works to ensure compliance with applicable laws and regulations.
3.A.5	Administration	Governing Body
3.A.6	Administration	University Finance Policies	Financial documentation and reports are handled by WKUHS's Office Coordinator and Assistant Director for Business Operations.
3.A.6.a	Administration		See 3.A.6
3.A.6.b	Administration		See 3.A.6
3.A.6.c	Administration		See 3.A.6
3.A.6.d	Administration		See 3.A.6
3.A.7	Administration	Governing Body
3.A.8	Administration	University Finance Policies	WKUHS follows university purchasing policies.
3.A.9	Administration	Governing Body WKUHS Org Chart	Health Services is a function of the University's Finance and Administration Division.
3.A.10	Administration	Records Management	WKU follows the Ky. State University Model Schedule for record management.
3.A.11	Administration	Governing Body
3.A.12	Administration	Clinical Records Network Security	WKUHS maintains an electronic health records system that allows us to collect and report data as necessary to meet the needs of our organization. Staff are expected to respect the IT resources used to perform these activities.
3.A.12.a	Administration		See 3.A.12
.i	Administration		See 3.A.12
.ii	Administration		See 3.A.12
.iii	Administration		See 3.A.12
3.A.13	Administration
3.A.14	Administration	Governing Body
3.B	Administration	University Policies Personnel Files	WKUHS follows university policies in addition to maintaining appropriate internal policies and procedures.
3.B.1	Administration	WKUHS Org Chart	See 3.B
3.B.2	Administration	Provider:Credential/Privilege	See 3.B
3.B.3	Administration	New Employee Orientation	New employees receive training from WKUHS & Human Resources.
3.B.3.a	Administration	New Employee Orientation	See 3.B.3
3.B.3.b	Administration	New Employee Orientation	See 3.B.3
3.B.3.c	Administration	New Employee Orientation	See 3.B.3
3.B.4	Administration		Employee evaluations are performed annually with a review of job descriptions.
3.B.5	Administration		See 3.B
3.B.6	Administration	University Policies	Human Resources periodically reviews compensation for all departments and at the request of the supervisor.
3.B.7	Administration	University Policies New Employee Orientation	See 3.B
3.B.8	Administration	University Policies New Employee Orientation	See 3.B
3.B.9	Administration	University Policies	See 3.B
3.C	Administration	B.B.P. Exposure Control	WKUHS maintains programs for infection prevention and employee safety as required by OSHA regulations with consideration of recommendations from CDC and other national health care quality organizations.
3.C.1	Administration	B.B.P. Exposure Control	See 3.C
3.C.2	Administration	B.B.P. Exposure Control	See 3.C
3.C.3	Administration	B.B.P. Exposure Control New Employee Orientation	See 3.C
3.D	Administration	B.B.P. Exposure Control Infection Prevention	See 3.C
3.D.1	Administration	B.B.P. Exposure Control	See 3.C & D
3.D.1.a	Administration	B.B.P. Exposure Control	See 3.C & D
3.D.1.b	Administration	B.B.P. Exposure Control	See 3.C & D
3.D.1.c	Administration	B.B.P. Exposure Control	See 3.C & D
3.D.1.d	Administration	B.B.P. Exposure Control	See 3.C & D
3.D.1.e	Administration	B.B.P. Exposure Control	See 3.C & D
3.D.2	Administration	Infection Prevention
3.D.3	Administration	Infection Prevention
3.D.4	Administration	Safety Handbook
3.E	Administration	Infection Prevention	Employee safety education and training is done in conjunction with university departments including Human Resources, Environmental Health & Safety and others as required by law.
3.E.1	Administration	Infection Prevention	See 3.E
3.E.2	Administration	Infection Prevention	See 3.E
3.E.3	Administration	Infection Prevention	See 3.E
3.F	Administration	Safety Handbook	See 3.E
3.G	Administration		WKU Human Resources maintains the university's Worker's Compensation program.
3.H	Administration		Patients are encouraged to take our satisfaction survey. Aggregate survey results and outlier responses are reported to the Executive Director and reviewed by the appropriate committees.
3.I	Administration		WKUHS follows financial aid, payroll and other applicable policies and processes for employing students and allowing postgraduate trainees to shadow our providers.

WKUHS AAAHC Accreditation : Administration