Deep Dive into AAC – Access, Assessment & Continuity of Care

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Ensuring Seamless Patient Journeys: A Deep Dive into NABH Chapter AAC (Access, Assessment & Continuity of Care)

The Access, Assessment, and Continuity of Care (AAC) chapter in the NABH 6th Edition is the backbone of quality healthcare delivery. It ensures that patients are not only able to access appropriate healthcare services, but that they are assessed correctly, treated timely, and handed over properly across departments and finally discharged with clarity and continuity.

Whether you’re preparing for NABH Entry-Level, Full Accreditation, or working on internal quality improvement, AAC compliance forms the foundation of patient care excellence.

🔹 AAC.1 – Scope of Services
Objective: The hospital must clearly define what services it offers and communicate this to patients, staff, and stakeholders.

1. Example:
   A 100-bedded multispecialty hospital offers services in General Medicine, General Surgery, Orthopedics, Pediatrics, and Critical Care. It also has an in-house lab and X-ray unit but outsources CT scan services.

Compliance Actions:

• List all departments and services on your website and SOP manual.
• Display service charts at reception and ER.
• Mention any outsourced services and justify them with vendor quality documentation.

🔹 AAC.2 – Admission and Initial Assessment
Objective: Every patient must undergo an initial assessment (vital signs, presenting complaints, history) within a defined time, followed by detailed assessment by a consultant.

Example:
In the ER, a trauma patient is triaged and assessed by a duty doctor within 10 minutes of arrival. The vitals are recorded, and a Glasgow Coma Scale score is calculated. The patient is then reviewed by the surgeon.

Tools to Use:

• Triage checklist
• ER Initial Assessment Form this is just a reference form for implementation form mail IFHP and we will share the bundle.
• MEWS/NEWS scoring templates

Tip: Keep time stamps on patient arrival and assessment in your HMIS for easy audit.

🔹 AAC.3 – Transfer and Referral (In & Out)
Objective: Transfers (within the hospital or to another facility) and referrals must be safe, documented, and involve proper handovers.

Example:
A critical patient is being referred to a higher cardiac center. The RMO prepares a referral note detailing treatment given, current vitals, medications administered, and ensures an ambulance is arranged with an attending nurse. A copy is given to the relative and receiving hospital.

1. Common Gaps Found in Hospitals:
   • Transfer summary missing or handwritten without legibility.
   • No documentation of verbal handover or receiving facility details.

Tip: Always use a printed Transfer/Referral Form with fields for name of referring doctor, summary of treatment, vitals, investigations done, and medications.

🔹 AAC.4 – Reassessment
Objective: All inpatients must be reassessed regularly. The frequency depends on their condition and risk level.

Example:

• ICU patients – reassessed every 2 hours.
• Ward patients – every 6 hours or during each nursing shift.
• Post-op patients – hourly for 6 hours post-surgery, then every 4 hours.

Red Flag Tools:

• Use Modified Early Warning Scores (MEWS) to predict patient deterioration.
• Ensure progress notes are updated by nursing and medical staff.

🔹 AAC.5 – Discharge Planning
Objective: The discharge process must be coordinated, informed, and include clear instructions on medication, follow-up, diet, and red flags.

Example:
Before discharge, the treating consultant reviews the final bill, discharge summary, and ensures the patient understands:

• When to return for review
• How to take new medications
• What symptoms to watch for post-discharge

Compliance Points:

• Discharge summary must have UHID, admission/discharge date, final diagnosis, treatment summary, medication list, and follow-up plan.
• Verbal counseling should be done and documented.

Audit Tip: Randomly call discharged patients after 48 hours to verify understanding of discharge instructions.

🔹 AAC.6 – Laboratory Services
Objective: Lab services should be provided as per hospital scope, with clearly defined procedures for critical value reporting.

Example:

• A patient’s potassium level is reported as 2.0 mEq/L (critically low).
• The lab immediately calls the ICU doctor, who reads back the value to confirm.
• The event is documented in a Critical Value Communication Log.

Checklist:

• Maintain list of ‘panic values’.
• Document who received the critical call and when.
• Conduct quarterly audits of TAT (Turnaround Time) for stat samples.

🔹 AAC.7 – Imaging Services
Objective: Imaging must be safe, timely, and accurate. Critical findings should be communicated urgently to treating teams.

Example:
A CT report shows a brain hemorrhage. The radiologist immediately calls the ER doctor. This call is logged and the patient shifted to ICU.

Points to Ensure:

• Daily QA checklist for imaging machines.
• Compliance with AERB guidelines.
• Documentation of communication for critical findings.
• Consents from Patients and Maintainance of Register

🔹 AAC.8 – Outsourced Services
Objective: If services are outsourced, they must be contracted with vendors that have quality systems (NABL/NABH preferred).

Example:
The hospital doesn’t have a 24×7 CT facility, so they refer patients to ABC Diagnostics. ABC is NABL accredited, and a formal MoU exists between the two.

What to Include in the Agreement:

• List of tests/services outsourced
• TAT commitment
• Sample transport and reporting process

🔹 AAC.9 – Radiation Safety
Objective: Radiation exposure should be justified, safe, and tracked under an appointed Radiation Safety Officer (RSO).

Checklist:

• Display ALARA principles.
• Use shielding and badges for staff.
• Maintain equipment calibration records.
• Create pregnancy exposure policy.

🔹 AAC.10 – Continuity of Care
Objective: Ensure smooth transitions between departments and across caregivers. Use structured handover forms and shift notes.

Example:

When ICU patient shifts to ward, handover includes current status, active medications, nursing needs, and pending investigations.

When duty doctors change, an ER shift note is signed with briefings on all active patients.

🔹 AAC.11 – DAMA (Discharge Against Medical Advice)
Objective: If a patient leaves against medical advice, the hospital must counsel, document, and have the DAMA form signed.

What to Include:

• Explanation of risks
• Signatures from doctor, patient, and relative
• Document patient’s reason for leaving

Note: If patient refuses to sign, document clearly with witness notes.

🔹 AAC.12 – Discharge Summary
Objective: Discharge summaries must include standardized content, written clearly, and handed to the patient at the time of discharge.

Must-Have Content:

• Diagnosis, treatment, condition at discharge
• Follow-up plan
• Medications with dose and frequency
• Cause of death in case of mortality

Tip: Include summaries in both English and regional language (if possible) to improve patient understanding.

Final Thoughts
The AAC chapter is not just about documentation—it’s about clinical responsibility. Every doctor, nurse, technician, and administrator has a role in ensuring:

• Timely assessments
• Safe handovers
• Meaningful communication
• Transparent transitions

Forum Discussion Questions:

1. How does your hospital document internal transfers between ICU and ward?
2. What tools are used for reassessment of patient risk in your facility?
3. How do you ensure that lab critical values are acted upon in less than 15 minutes?

Let’s start the conversation and help each other improve AAC compliance across institutions!

 

References:

1. NABH
2. CAHO PPT on NABH

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