Gap Analysis

Our Gap Analysis and Corrective Action Plan is a three-day, on-site evaluation designed to identify every operational, clinical, and governance gap that could prevent your pregnancy medical clinic from meeting AAAHC accreditation standards.

During the visit, we conduct an in-depth assessment across all key areas of your organization — including board governance, personnel files, medical credentialing, facility safety, privacy and security compliance, infection control, and patient care documentation.

Scope of Work

• Governance & Board Compliance: Review bylaws, meeting minutes, and board files to ensure compliance with IRS and AAAHC standards, confirming each member has current job descriptions, conflict of interest statements, and signed policy acknowledgments.
• Personnel & Medical Staff Files: Audit all staff, volunteer, and medical professional files for completeness, consistency, and proper documentation of credentials, job descriptions, and annual reviews.
• Clinical Operations: Evaluate patient charting, consent processes, privacy acknowledgments, and standing orders for medical accuracy, risk management, and alignment with best practices.
• Facility & Safety Inspection: Conduct a full walkthrough using a detailed facility checklist covering emergency preparedness, hazardous waste management, infection control, utilities, fire safety, and OSHA standards.
• Privacy & Security Compliance: Assess adherence to HIPAA-equivalent privacy laws, electronic medical record access, encryption, and data storage policies.
• Quality Improvement & Risk Management: Identify missing logs, committee structures, and documentation needed to demonstrate a functioning QI program and ongoing peer review.

Deliverables – Following the site visit, you’ll receive:

1. A comprehensive written report detailing findings, organized by category and level of urgency.
2. A Corrective Action Plan prioritizing each item with recommended solutions, responsible parties, and compliance guidance.
3. A Facility Safety and Hazard Checklist with itemized notes, photographs (as applicable), and links to compliant products or references.
4. Updated or model policies and procedures where deficiencies were identified.

Outcome:

The deliverables provide the first steps for becoming AAAHC compliant — reducing risk, strengthening governance, protecting patient safety, and ensuring you are survey-ready.