Annual report offers quantitative and qualitative analysis,
guidance for sustainable quality improvement
(Deerfield, Ill.) Nov. 29, 2023 – Today, the Accreditation Association for Ambulatory Health Care (AAAHC) releases its 2023 AAAHC Quality Roadmap, a comprehensive analysis of data from nearly 1800 accreditation surveys conducted in a cross-section of organizational types from January 2022 to February 2023. The annual report helps providers identify themes that deserve special attention as organizations pursue ongoing quality improvement throughout the accreditation cycle.
“Every year, our analysis provides valuable information for ambulatory facilities to evaluate their performance and determine measures they may take as part of their accreditation journey,” said Noel Adachi, MBA, president and CEO of AAAHC. “We encourage health care facilities to use this data and accompanying analysis to guide decision-making and start conversations about how to implement best practices now and throughout the 1,095 days of their accreditation term.”
The Quality Roadmap provides in-depth insight based on data from surveys of organizations seeking initial or reaccreditation in the Ambulatory Accreditation (AMB) and the Medicare Deemed Status (MDS) programs. Organizations surveyed include ambulatory surgery centers (ASC), office-based surgery practices (OBS), and primary care settings (PC). OBS settings include diagnostic imaging centers, fertility centers, oncology centers, and office-based anesthesia organizations.
This report provides an analysis of the highest and the lowest compliance findings for those Standards that were applicable to at least 95% of the organizations surveyed:
Findings on High Deficiency Standards
Data show that health care facilities can continue to strengthen operations and survey readiness by improving key standard processes. Although the observed deficiencies, such as personnel and quality of care, are similar to previous year findings, a few critical areas related to emergency preparedness, documentation management, and credentialing and privileging, require dedicated facility attention with specific considerations and strategies to address current national labor shortages.
Findings on High Compliance Standards
In addition to high deficiency Standards, the Quality Roadmap also indicates that accredited organizations have shown sustained compliance or notable improvement in several key areas:
Ambulatory Status Standards
- Meeting at least annually, or more frequently as determined by the governing body, to discuss key business matters.
- Providing and supporting ongoing professional development for staff.
- Maintaining written procedures for managing medical emergencies and unplanned outcomes for which transfer to a higher level of care is indicated to treat patients.
- Complying with national patient confidentiality standards for medical documentation.
- Ensuring patients receive proper individual clinical records, when applicable.
- Documenting and investigating workplace injuries and illnesses, when applicable.
Medicare Deemed Status Standards
- Complying with regulations that meet requirements for emergency service payment.
- Ensuring that organizations protect the confidentiality of individual’s health records and personal information.
- Appointing qualified physicians, dentists, etc. to supervise surgical procedures on site.
- Maintaining written policies regarding procedures and treatments offered to patients.
- Providing patients with comprehensive post-operative care and discharge instructions, when applicable.
- Ensuring pharmaceutical services are directed by a qualified, licensed professional.
Leveraging the Quality Roadmap in your facility
The report is designed to help providers understand common deficiencies and compare these findings to their most recent onsite report and annual self-assessment. Facilities are encouraged to share and discuss findings with others in the organization to help drive decision-making on possible quality improvement studies or other corrective action. Additional guidance addresses patient safety toolkits and other AAAHC resources to improve and ensure quality. Specifically, AAAHC recently revised toolkits to help organizations establish, reevaluate, and/or improve their credentialing and privileging and emergency preparedness, and new surgical considerations for obesity and obstructive sleep apnea (OSA).
“The Quality Roadmap is an essential industry tool to ensure that accredited organizations can allocate resources to celebrate their success as well as prioritize and address noted deficiencies and areas for improvement,” said Julie Lynch, MS, BSN, RN, director, Institute for Quality Improvement. “This report uses a data-lead approach to address ongoing deficiencies, such as documentation and emergency preparedness, by providing process guidelines, digital tools and educational opportunities for health care providers.”
Download the Quality Roadmap today at www.aaahc.org/quality-institute/quality-roadmap/.
