On June 16, AAAHC released its 2021 Quality Roadmap, a comprehensive analysis of data from more than 1,120 accreditation surveys conducted in 2020. The Quality Roadmap serves as a resource for health care organizations to identify themes for careful consideration and provides useful benchmarks for strengthening ongoing quality improvement efforts.
“Complying with AAAHC Standards requires relentless vigilance on practices that impact staff and patient safety,” said Noel Adachi, MBA, president and CEO of AAAHC. “By reviewing the successes and challenges of peer ambulatory health care facilities outlined within the Quality Roadmap, organizations can identify best practices for conducting quality improvement studies, comply with credentialing and privileging standards, manage documentation, and more as they work to provide the highest quality of care.”
The 2021 report examines accredited organization compliance ratings for AAAHC Standards based on onsite surveys conducted January 1-December 31, 2020. Organizations surveyed include ambulatory surgery centers (ASC), Medicare Deemed Status ASCs (MDS ASC), office-based surgery practices (OBS) and primary care settings (PC).
Findings on High Deficiency Standards
The 2020 data show a few new areas related to infection prevention/safe injection practices which reached the 10% deficiency threshold, indicating that organizations should continue to address infectious disease protocols and emergency preparedness plans, including COVID-19 safeguards. The report also contains analysis of deficiencies related to processes that prevent errors from high-alert and confused drug name medication; proper cleaning and decontamination of equipment; and the recall of items including drugs and vaccines, blood products, medical devices, equipment and food products.
Findings on High Compliance Standards
In addition to high deficiency standards, the analysis also indicates that accredited organizations have shown improvement in key areas within non-Medicare and Medicare Deemed Status Standards, including:
Non-Medicare Deemed Status Standards
- Maintaining governing body records of meetings and decisions
- Defining authorities of employed, elected and appointed officers and administrators
- Recording and investigating work-related injuries and illnesses
- Complying with building codes and regulations
- Ensuring that whenever patients are present in the facility, qualified personnel are onsite to address medical emergencies
- Conducting interviews or observations of patient interactions, confirming that patients are being accurately informed about safe and effective use of medications
Medicare Deemed Status Standards
- Conducting periodic reviews of federal or state risk management requirements
- Ensuring patients have the right to receive care in an environment free of harassment, discrimination and reprisal
- Providing easy access to current drug information and other decision support resources for health care professionals who prescribe, dispense, administer and provide patient education
- Having readily available clinical information for authorized personnel whenever the organization is open to patients
- Providing adequate supervision of surgical services
- Ensuring that a registered nurse is directing nursing services
- Assisting patients with the transfer of care from one health care professional to another
“The Quality Roadmap brings 1095 Strong, quality every day to life by outlining common pain points and highlighting the importance of accreditation readiness, quality improvement, and ongoing monitoring of processes and procedures,” said Hallie Brewer, senior vice president, learning & development. “The goal of accreditation is ongoing compliance with AAAHC Standards in order to consistently deliver high quality, safe patient care. This report provides an overview of common areas of high deficiency along with expert advice for strengthening and maintaining compliance all 1,095 days of the accreditation term.”
To further assist organizations, AAAHC will host a webinar focusing on the Quality Roadmap report on June 16. The 2021 AAAHC Quality Roadmap is available for download at www.aaahc.org/quality/aaahc-quality-roadmap/.
For more information on AAAHC, visit www.aaahc.org.
