FREQUENTLY ASKED QUESTIONS

AAAASF answers frequently asked questions about accreditation, patient safety data reporting and other topics

Patient Safety Data Reporting FAQs

  • How do I change or add my Patient Safety Data Reporting Administrator?

    The Medical Director must complete the “Patient Safety Data Reporting Administrator Authorization Form” located on the AAAASF website under Patient Safety Data Reporting Documents. The completed form should be emailed to [email protected].
  • What if I don’t remember my facility password?

    Simply click the Forgot your password? link on the Patient Safety Data Reporting login screen. You will then be prompted to enter your email address. Be sure to use the designated facility administrator’s password. You will then receive an email from [email protected] with a link to reset the facility password. Call the help desk at 224-643-7704 if you need further assistance.
  • Do we have to enter the data for the first case of every month for each surgeon/proceduralist?

    Yes, AAAASF standards require providers to submit Patient Safety Data Reporting information for the first case of every month for each surgeon.
  • What if a surgeon/proceduralist didn’t perform any cases in one of the months?

    If a surgeon/proceduralist has not performed at least one (1) case per month, cases from other months in the period may be selected for a total of three (3) reported cases per period.

  • What if a surgeon/proceduralist performs fewer than three cases during the period?

    If a physician using the facility has performed fewer than three (3) cases during a reporting period, that information must be reported to the AAAASF office using the Exemption form. All cases that were performed during that period must be reported through the online system.

General FAQs

  • What is accreditation?

    An accredited facility must comply with the most stringent set of applicable standards. It must meet our strict requirements for facility director, medical specialist certification, staff credentials and must pass a thorough survey by a qualified AAAASF facility surveyor. An accredited facility must be fully equipped to perform procedures in the medical specialty or specialties listed on its accreditation application and must be equipped to respond to emergencies.
  • How do you achieve accreditation?

    To achieve AAAASF accreditation, a facility must comply with 100% of the standards in all categories of AAAASF standards. Upon approval, an accredited facility must prominently display in public its accreditation certificate.
  • How do you maintain accreditation?

    An accredited facility must undergo re-evaluation through a self-survey, an onsite survey every three years and comply with all AAAASF accreditation standards.
  • How long does it take to become accredited after you apply?

    Once your paperwork is complete and your floor plan is approved, the AAAASF staff can usually secure a surveyor to evaluate your facility within 30 days. For Medicare accreditation, an additional Life Safety Code inspection is performed prior to the AAAASF Medicare inspection and AAAASF cannot guarantee a survey within 30 days. AAAASF does offer an expedited survey fee. Once completed, all new facilities are sent to an accreditation committee for approval. After approval is granted, accreditation is activated and the facility notified. Statistically, most facilities fully achieve accreditation 90 to 150 days after submitting an application.

    For those requesting an immediate survey in a non-Medicare program, we may be able to accommodate but an additional fee would apply.

  • How much does it cost to apply for accreditation?

    Prices vary based on program, facility size and number of specialists. Fee schedules are located in the application for the respective program.
  • What is Patient Safety Data Reporting?

    AAAASF’s patient safety data reporting system, as required by AAAASF’s standards, requires online reporting every three months. This online reporting includes the submission of three random cases for each surgeon/proceduralist and all unanticipated sequelae. The reported cases for each surgeon/proceduralist must include the first case done by each surgeon/proceduralist per month during the reporting period for a total of three cases, plus all unanticipated sequelae. If a surgeon/proceduralist has not performed at least one case per month, cases from other months in the period may be selected for a total of three reported cases per period.

    Peer Review versus Patient Safety Data Reporting
    What AAAASF previously called Peer Review is a separate and distinct process from what many physicians are familiar with as a full clinical peer review process, which is performed at a physician-to-physician level. The objective data elements required during the quarterly Patient Safety Data Reporting, as part of the accreditation process, is specifically intended for medical study and the evaluation and improvement of quality care and reduction of morbidity and mortality. Such data can be entered prior to the facility conducting its peer review meetings. Revised standards manuals will be published in the near future and will use more distinct language to demonstrate the difference.

    As we fully transition from referring to this process as Peer Review to Patient Safety Data Reporting, be aware that our online reporting portal may continue to reflect the term Peer Review for a time until all of our vendors have completed updates to the systems they administer on our behalf.

  • If I have questions not listed here, how can I get the answer?

    Contact us and speak with one of our accreditation specialists who will be happy to assist.