AAAHC 2023 V42 Update

Cathy Montgomery, RN, CASC and Sandra Berreth, RN, BS, MS, CASC have a one hour 20 minute review of the AAAHC changes for 2023 known as version 42. This presentation is for those that are currently AAAHC accredited and need to know updates and changes. This presentation is not intended to be everything A-Z for newbies to AAAHC.
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AAAHC 2023 V42 Update

AAAHC has updated their standards and they go into effect 3/1/23! Excellentia Advisory Group is here to help you understand the subtle changes and the long-term plan. We have invited Sandy Berreth, one of our consultants, to join in on this presentation. Sandy is an RN who has been with AAAHC since 2009 doing surveys for both deemed and non -deemed facilities. She will be able to explain how you should go about implementing changes in your organization to help you sail through your next survey.  She is currently doing surveys weekly, so her tips on common citations will be very valuable information.

About Our Speakers:  

Cathy Montgomery, RN, CASC                                                                                           Cathy Montgomery

Cathy has over 25+ years in healthcare services management. As Regional Administrator for NovaMed, she oversaw operations of the physician practices as well as surgery centers, and optical shops in the metro St.Louis/Illinois area. Cathy is President and Founder of Excellentia Advisory Group, a consulting and development company serving both the surgical industry through ASC'S as well as surgical hospitals and the outpatient industry through physician practices and ancillary centers. Cathy for the past several years has studied all the regulatory agencies that impact the ASC industry and has made herself an expert on the subject. Cathy is a frequently speaker at State ASC conferences to speak on regulatory compliance topics.  Cathy also offers expertise in running the day-to-day operations of a surgery center and assists several privately-owned surgery centers across the country as their management company. Her vision is to offer services that will be cost effective for her clients and fill those gaps that occur due to immediate needs. She has hired consultants that are knowledgeable and follow TJC, QUAD-A and/or AAAHC standards.  Cathy herself became an AAAASF surveyor in 2016 and now IMQ in 2018. Cathy has her CASC certification.


     Sandra "Sandy" Berreth, RN, BS, MS, CASC

Sandy has been in the ambulatory surgery center industry for over 23 years.  She has held all areas of clinical roles in her career leading up to clinical management and key roles as Administrator for a few surgery centers. Originally from the State of North Dakota as the Administrator of St. Alexis Same Day Surgery Center, she relocated to Minnesota where she was the Administrator of Brainerd Lakes Surgery Center for 11 years. Most recently Sandy has been the Director of Surgical Services for Sansum Clinic/ASC organization for 6 years.  Simultaneously and during the past 14 years, Sandy has been an AAAHC surveyor. Sandy has conducted over 350 surgery center surveys over this period of time and continues to survey one to two surgery centers per week. This expertise makes Sandy an outstanding addition to the Excellentia consulting team and an expert speaker on today's presentation subject matter.

Some key areas we will be explaining is the process AAAHC is moving towards with “Universal” and “Selective” standards. Other key elements include:

  • Policy requirement for transfer of a patient to a higher level of care
  • Expectations should you encounter a patient with an obvious communicable disease
  • How to manage your drills, documentation and how many you need
  • The pre anesthesia assessment requirement
  • How to update your H& P policy (example provided!)
  • Requirements for current references to nationally recognized guidelines
  • How to manage peer review (worksheet provided)

In addition, we will be providing you an example of an infection prevention plan, infectious disease risk assessment, current high alert medication list and current confused drug name list. All intended to keep you up to date for 2023.

You will also receive a notetaking version of the Powerpoint slide presentation.

As always, should you have any questions after listening to the VUD, Cathy and Sandy are available for your specific questions.  Excellentia’s goal is to be partnering with our clients for success in their day-to-day operations of the ASC.  We are only an email or phone call away.


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