AAAHC:Governance

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
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
2.A.2	Governance	Governing Body	BOR Bylaws
2.B	Governance	Governing Body
2.B.1	Governance	Governing Body WKUHS
2.B.2	Governance	Governing Body Staff	Staff are credentialed and privileged based on their abilities, education and job requirements.
2.B.3	Governance	Governing Body WKUHS Org Chart
2.B.4	Governance	Governing Body
2.B.5	Governance	Governing Body University Policies	WKUHS follows university policies in addition to maintaining appropriate internal policies and procedures.
2.B.5.a	Governance	Governing Body Care of Minor Patients	WKUHS has procedures in place to obtain consent to care for underage patients.
2.B.6	Governance	Governing Body Quality of Care	See sections on Quality of Care and Quality Management & Improvement.
2.B.7	Governance	Governing Body	Legal matters are handled by university counsel.
2.B.8	Governance	Governing Body	Meeting minutes are made available to staff.
2.B.9	Governance	Governing Body
2.B.10	Governance	Governing Body Patient rights and Responsibilities
2.B.11	Governance	Governing Body	WKUHS maintains personal service contracts.
2.B.11.a	Governance	Governing Body	See 2.B.11
2.B.11.b	Governance	Governing Body	See 2.B.11
2.B.11.c	Governance	Governing Body	See 2.B.11
2.B.11.d	Governance	Governing Body	See 2.B.11
2.B.11.e	Governance	Governing Body
2.B.11.f	Governance	Governing Body After Hours Care	Information listed on doors, website and phone messages.
2.B.11.g	Governance	Governing Body	WKUHS does not accept Medicare or Medicaid.
2.B.11.h	Governance	Governing Body	See 2.B.11
2.B.11.i	Governance	Governing Body	See 2.B.11
2.B.12	Governance	Governing Body
2.B.13	Governance	Governing Body University Policies	See 2.B.5
2.B.14	Governance	Governing Body WKUHS	Marketing materials are updated on a regular basis and are as accurate as possible.
2.B.15	Governance	Governing Body Risk Management Plan
2.B.16	Governance	Governing Body	See 2.B.5
2.B.17	Governance	Governing Body B.B. P. Exposure Control
2.B.18	Governance	Governing Body	WKUHS reports to the NPDB as required.
2.B.19	Governance	Governing Body Infection Prevention
2.B.20	Governance	Governing Body Patient Grievances
2.B.21	Governance	Governing Body Incident Reporting	The Incident Review Committee monitors and creates action plans when incidents occur.
2.B.21.a	Governance	Governing Body	see 2.B.21
.i	Governance	Governing Body	see 2.B.21
.ii	Governance	Governing Body	see 2.B.21
.iii	Governance	Governing Body	see 2.B.21
.iv	Governance	Governing Body	see 2.B.21
2.B.21.b	Governance	Governing Body	see 2.B.21
2.B.21.c	Governance	Governing Body	see 2.B.21
2.B.21.d	Governance	Governing Body	see 2.B.21
2.B.21.e	Governance	Governing Body	see 2.B.21
2.C	Governance	Governing Body
2.D	Governance	Governing Body	The Governing Body maintains meeting minutes.
2.D.1	Governance	Governing Body	See 2.D
2.D.1.a	Governance	Governing Body	See 2.D
2.D.1.b	Governance	Governing Body	See 2.D
2.D.1.c	Governance	Governing Body	See 2.D
2.D.1.d	Governance	Governing Body	See 2.D
2.D.1.e	Governance	Governing Body	See 2.D
2.D.1.f	Governance	Governing Body	See 2.D
2.D.1.g	Governance	Governing Body	See 2.D
2.D.1.h	Governance	Governing Body	See 2.D
2.D.1.i	Governance	Governing Body	See 2.D
2.E	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.G	Governance	Provider:Credential/Privilege	See 2.A

WKUHS AAAHC Accreditation : Governance