To ensure policies are evidence-based, follow national standards of practice, and comply with state and local laws, rules, and regulations, each organization must have policies and procedures reviewed and approved by the appropriate committees at the defined frequency stated in the standards and in accordance with hospital policy.
According to Accreditation Commission for Health Care (ACHC) Accreditation Standards, a critical access hospital’s written policies governing patient care services must be developed with the advice of members of the hospital’s professional healthcare staff. This advisory group must include:
- At least one Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO).
- At least one non-physician practitioner (physician assistants, nurse practitioners, or clinical nurse specialists), if these professionals are included in the CAH’s healthcare staff, as permitted at §485.631(a)(1). A critical access hospital with no non-physician practitioners on staff is not required to obtain the services of an outside non-physician practitioner to serve on the advisory group.
The advisory group not only makes recommendations for new patient care policies but also is expected to review the existing patient care policies at least biennially (every two years), and, if it concludes that changes are needed, recommend those changes. Policies must be reviewed and, as applicable, revised more frequently when required, for example, in response to a change in federal or state regulations to which the critical access hospital is subject. The hospital must maintain documentation that provides evidence that the advisory group has conducted its reviews and made recommendations concerning patient care policies.
Final Approval of Policies: Although a CAH’s patient care policies are developed and periodically reviewed with the advice of members of the professional healthcare staff, the final decision on the content of the written policies is made by the CAH’s governing body or individual responsible for the CAH, consistent with the requirement at 42 CFR §485.627(a). If recommendations of the advisory group are rejected, the governing body must include in the record of its adoption of the final written policies its rationale for adopting a different policy than that recommended.
Listed below are ACHC Critical Access Hospital (CAH) Standards that require policy approvals by various committees, including the medical staff. Other policies or documents not listed below should be defined in the policy and procedure approval policy. This is not an all-inclusive list, so please refer to specific standards for detailed guidance.
