The Accreditation Process
University Health Services is a fully accredited ambulatory health care center that achieved full re-accreditation by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) in 2015. The survey process "in a nutshell"...
- The accreditation decision is based on a careful and reasonable assessment of an organization's compliance with applicable standards and adherence to AAAHC policies and procedures. AAAHC selects and trains health care practitioners and administrators who are actively involved in ambulatory health care setting to conduct accreditation surveys. Compliance with standards is assessed through documented evidence, answers to detailed questions concerning implementation and on-site observations and interviews by surveyors.
UHS maintains an active, organized, peer-based program that assures quality services to its clients. The Quality Improvement Program at UHS enhances the quality of patient care and educational services through the on-going systematic monitoring and evaluation of important aspects of that care and resolution of identified problems that impact on patient care.
The program is overseen by the Quality Improvement Committee, an interdepartmental group of representatives from all areas within UHS.
A comprehensive process exists to ensure that credentialing of appropriate staff* is validated and a copy maintained on file. At the time of renewal of credentials, staff are required to present originals of renewed credentials to the Director or designee for review. All UHS physicians are board certified or board eligible in a primary care specialty.
The objective of peer review is to create a positive learning experience between peers (physicians, nurse practitioners, and physician assistants) for the benefit of improving patient care.
During each semester, clinicians complete peer chart reviews in small groups. Participants review, discuss, and document each chart. In addition, professional staff have a regular peer review conference at which they discuss challenging and difficult cases.
The health service-wide risk management program is designed to protect the life and welfare of UHS patients, employees and visitors. The program enhances the safety of the health service environment through an on-going process designed to detect, evaluate, and to the greatest degree possible, reduce risk by eliminating problems that might result in harm to patients, staff, visitors, or UHS.
UHS assures that all health care providers, supporting health services staff, and student volunteers/students working in UHS, adhere to established ethical principles and codes of professional practice including patient confidentiality, privacy, dignity, and informed consent. As a patient of UHS, you also have certain Rights and Responsibilities. We encourage you to review these and to ask questions if you have any concerns.
* UHS Staff; Physicians, Physician Assistants, Nurse Practitioners, Registered Nurses, Licensed Practical Nurses, Registered Dieticians, Pharmacists, Physical Therapists, Physical Therapy Assistants, Medical Technologists, X-Ray Technologists, Emergency Medical Technicians