Western Kentucky University

WKUHS AAAHC Accreditation : Surgical & Related Services

Adjunct Chapter_only applicable standards will be adressed    
I.D. Chapter Evidence Notes

10 

Subchapter 1 -General Requirement 

 

 

10.A 

Surgical and Related Services 

Cleaning and Disinfecting

Provider:Credential/Privilege

 Procedures performed at WKUHS are done by qualified, credentialed providers in a safe and sanitary environment.

 10.B

 Surgical and Related Services 

 

 Only minor procedures are performed at WKUHS ie: suture removal. These services are provided by credentialed providers under direction of the medical director.

 10.C

Surgical and Related Services 

Provider:Credential/Privilege

 See 10.A

 10.C.1

Surgical and Related Services 

Provider:Credential/Privilege

 See 10.A

10.C.2

Surgical and Related Services 

Provider:Credential/Privilege

 See 10.A

10.D

Surgical and Related Services  

Health histories are updated at each visit as appropriate. WKUHS only performs minor procedures and does not use general anesthesia.

10.E

 Surgical and Related Services This item is not applicable.

 

 10.F

 Surgical and Related Services

This item is not applicable.

 

10.G 

Surgical and Related Services  Informed Consent

 Consent forms are obtained prior to performing procedures.

 10.H

Surgical and Related Services  Ancillary:Credential/Privilege

 

10.I 

Surgical and Related Services   

 Procedure rooms are equipped for minor procedures as performed by WKUHS providers.

 10.J

Surgical and Related Services   

 All WKUHS staff members receive CPR training.

 10.J.1

Surgical and Related Services 

This item is not applicable

 

 10.K Surgical and Related Services   

A provider is always in the facility with patients during normal operating hours.

 10.L Surgical and Related Services 

Lab Tests-General Information

 The WKUHS lab is CLIA certified.

10.M  Surgical and Related Services   

 All procedure documentation is added to the EHR.

 10.N Surgical and Related Services 

Infection Prevention

Instrument Sterilization

 

10.N.1  Surgical and Related Services  Patients with Communicable Disease

 

 10.N.2 Surgical and Related Services 

This item is not applicable.

 

 10.N.3  Surgical and Related Services Hand Hygiene

Policies and processes are in place to reduce chances for infection during procedures.

 10.N.4 Surgical and Related Services 

Hand Hygiene

 

10.N.5 Surgical and Related Services   

 Patient permission is received before a non-WKUHS clinical staff (including visiting health care trained students) or visitor is asked to be in the room. Non-WKUHS clinical staff (excluding police only when neccessary) are not allowed in a procedure room while  a patient is being seen.

 10.N.6 Surgical and Related Services 

Infection Prevention

 Environmental surveillance is done on a monthly basis to catch issues as they arise.

10.N.7  Surgical and Related Services 

Infection Prevention

 See 10.N.6

10.N.8 Surgical and Related Services 

Infection Prevention

 

 10.N.9 Surgical and Related Services 

This item is not applicable.

 

 10.N.10 Surgical and Related Services   

Blood stained  PPE used by staff and/or coverings used by patients are appropriately disposed.

 10.N.11 Surgical and Related Services 

This item is not applicable.

 

 10.N.12 Surgical and Related Services 

 

 Cautery is not used at WKUHS.

 10.N.13 Surgical and Related Services 

Infection Prevention

 

 10.O Surgical and Related Services 

Instrument Sterilization

WKUHS maintains properly sterilized instruments. 

 10.O.1 Surgical and Related Services 

Instrument Sterilization

See 10.O 

10.O.2  Surgical and Related Services 

Instrument Sterilization

See 10.O

10.P  Surgical and Related Services 

This item is not applicable.

 

 10.Q Surgical and Related Services 

This item is not applicable.

 

 10.R Surgical and Related Services 

Environmental Health & Safety

An alternate source of power is available for essential equipment in the event of power outages. Periodic checks are performed by EHS. 

 10.S Surgical and Related Services 

Medical Equipment Testing

All medical equipment is tested on an annual basis. 

 10.T  Surgical and Related Services

Informed Consent

See 10.G 

 10.U  Surgical and Related Services

Time Out Procedure

 

 10.V  Surgical and Related Services

Time Out Procedure

 

 10.W Surgical and Related Services 

This item is not applicable.

 

10.X  Surgical and Related Services 

This item is not applicable.

 

 10.Y  Surgical and Related Services

This item is not applicable.

 

10.Z Surgical and Related Services

Care of Minor Patients

 Only appropriately trained and credentialed providers perform minor procedures on younger patients. WKUHS also maintains child sized items in the event of an emergency.

 Last Modified 10/2/13