*Type of Applicant Center:
Select atleast one choice
In Patient Hospital/Medical Center
Outpatient Ambulatory Surgery Practice
Medical/Multidisciplinary Practice
Behavioral Health/Mental Health/Nutrition Health Practice
Business Model: ( You can check more than one )
Not-for Profit
Corporation
Limited Liability Corporation
Sole Proprietor /Private Practice
Government Center
note : atleast 1 need to be selected.
Name, title, and contact information of organization’s Leadership.
4. Executive Summary and Background: This Executive summary is intended to provide the COTE application survey team with an overview of the services/treatment modalities provided for your patient population. You can include center’s mission/philosophy, and why the applicant is uniquely qualified to receive the designation of Center of Therapeutic Excellence. This summary could also identify health professionals that are most instrumental in facilitating the mission and goals of your center ( 750 words maximum ).
Insert [ ✓ ] in each of the following statements to attest that the applicant is in compliance :
The applicant is a legal entity and is properly licensed, certified or accredited to operate in the jurisdiction in which it is located.
The applicant or any of the applicant’s employees, agents, independent contractors or sub-contractors have not been convicted of, pled guilty to or pled nolo contendere to any health care related offence.
The applicant has no current or pending disciplinary actions.
applicant is in good standing with all regulatory agencies.
The applicant has read, understands, and accepts the mandatory requirements, responsibilities, and terms and conditions associated with these COTE accreditation standards.
The applicant does not discriminate in its employment practices with regard to race, color, religion, age, sex, marital status, sexual orientation, political affiliation, national origin, or handicap.
The applicant follows all required safety protocols, has safety policies in place, and has established emergency protocols for health and safety related incidents.
The applicant has in place all furniture, fixtures and medical and surgical equipment and appropriate infrastructure needed to accommodate and facilitate the care of obese individuals.
If your center does not fully complywith any of the above attestations please provide an explanation (max 200 words)
Attach list of current Board of Directors/Trustee or advisory board Member(if applicable)
(+) add more accreditation
Licenses:
(+) add more Licenses
Certificate:
(+) add more Certificate
Not Applicable
The applicant supports Continuing Education Programs to keep health care providers current with emerging science related to obesity/diabesity management.
The applicant has policies and procedures in place to protect sensitive patient health care information from being disclosed without the patient consent or knowledge.
The applicant has process in place for dispute resolution for both patient and staff.
The applicant agrees to participate in collaborative sharing of anonymous data to aid in applicable research
applicant has a referral plan in place for allied supplementary support services.
If applicant does not currently comply with the above policies, please explain below
The number of Health Care Professionals who are AABC Board Certified in Bariatric Science – Please include names and AABC Certification no.
(+) add more
The number of Health Care Professionals on the Interdisciplinary Team who will enroll in the AABC Board Certification in Bariatric Science Program in the next year.
The applicant has an Interdisciplinary Team in place to provide for the multifactorial needs of the bariatric population or selected specialized supplementary referral services
The applicant has on file a current record of all CV’s, resumes, license/certification/registration of all health professionals
The applicant has a plan in place to support Continuing Education in Bariatric Science for all health Care Professionals.
The applicant provides sensitivity training for all Healthcare Professionals and ancillary staff.
The applicant will actively participate in and promote Public Health Education in the community it serves.
The applicant recognizes Obesity as a chronic condition that requires life-long Interdisciplinary approach.
The applicant has treatment protocol in place for relapses as well as relapse prevention.
Mental Health Professionals employ evidence-based counseling techniques and interventions that target the psychosocial implications of obesities
The applicant informs patients of all available treatment options, both surgical and non-surgical.
The applicant recognizes the significance of psychological and behavioral achievements and not merely weight reduction.
Health Care Professionals are knowledgeable about long-term, psychological, nutritional, medical needs of patients who have had bariatric surgery and provide care consistent with established best practices.
Health Care Professionals will discuss with patients, and or prescribe approved medications for the treatment of obesity.
Health Care Professionals will not recommend or refer patients to obesity treatments for which the potential risk and cost outweigh the expected health benefits for a given individual.
The applicant will provide ongoing in service professional education addressing the needs of bariatric patients.
The applicant has in place a process and resources for ongoing patient and staff education (Nutrition, Mental Health, Physical Health, Behavioral Health etc.).
The applicant will provide both pre and post bariatric surgery education for patients and staff.
The applicant will provide evidenced based weight management options for patients not requiring or desiring weigh loss surgery.
The applicant has a procedure in place to inform patients of their responsibilities as a participant in the program.
The applicant requires all program participants to sign consent forms for service and to give permission to release health information to all Health Care Professionals within their COTE network.
The applicant maintains all consent forms in the patient’s medical record.
Mention type of surgery services provided in your facility( If applicable):
Not Applicable ( )
Check each of the services you currently provide:
Comprehensive Weight Management Program with individual counseling
Metabolic health and Weight Management Support Group
Has network of selected -specialties for easy referral
Other
If other, please explain
The applicant has a Continuous Quality Improvement Program in place to monitor the care provided and identify opportunities to improve patient care services.
The applicant will adhere to all accreditation standards that support quality improvement and that lead to patient satisfaction and successful outcomes.
The applicant agrees to provide quality Improvement data to AABC if requested.
The applicant conducts regular Quality Improvement surveys.
The applicant schedules interdisciplinary staff meetings to discuss all aspects of patient care.
Indicate how often the QI Plan is updated:
Annually
Bi-Annually
Check the statements provided below ensuring that the applicant will comply with requirements relating to Eligibility Determination:
The applicant will permit AABC/COTE accreditation vetting team inspection access to their center, upon mutually scheduled request, when and if required and deemed necessary for the accreditation process.
The applicant permits AABC/COTE accreditation vetting team the authority to perform, all background, investigative and auditing procedures necessary to facilitate the applicants accreditation request
The applicant verifies the veracity and accuracy of the all the application information that has been provided.
The applicant indemnifies and holds harmless AABC/COTE from all agreements, contracts with third parties with which they have entered into.
The applicant agrees that AABC/COTE shall store & archive information about the applicant in a reliable confidential manner which is not accessible for unauthorized persons. Stored information will only be accessible upon consent from applicants authorized representatives
The applicant and applicant’s employees, consultants, contractors shall adopt all necessary measures to ensure that all information and/or technical knowledge exchanged with AABC/COTE remain strictly confidential and will not be shared with third parties
The applicant shall ensure the timely remuneration of its fees or dues to the AABC/COTE. AABC/COTE shall have the right to adjust fees unilaterally.
The applicant upon voluntary non- renewal of AABC/COTE accreditation will cease and desist in the use of AABC/COTE recognized accreditation, logo, AABC/COTE award plagues, certificates and cannot maintain the they are an AABC/COTE accredited center,
Applicant understand that application fees are non-refundable.
The applicant has the responsibility to maintain the fundamental core standards required for renewal of accreditation .
The applicant will familiarize all new staff member with AABC/COTE accreditation standards and goals
The Applicant understands that AABC/COTE reserves the right to deny, accreditation or suspend or revoke the Center of Therapeutic Excellence accreditation should the applicant fail to comply with established standards.
For additional assistance with your application or any further guidance please contact COTE committee at: e-mail: cote@aabc-certfication.org , Tel: 1-866-284-3682
Authorized Signature of Applicant (from section 2 (leadership) of this application)
