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Quality Improvement in the Accreditation Process

Quality improvement is fundamental to AAAHC accreditation. The aim is simple but far-reaching: to promote a consistent, pervasive drive toward making things better across an organization.

As a means of documentation, AAAHC asks each organization seeking accreditation to provide examples of two completed quality improvement (QI) studies at each three-year survey. These studies demonstrate that the organization is meeting a minimum requirement, but what we really hope to see is that accredited organizations are engaged in continuous action to achieve measurably better outcomes — in clinical care, patient satisfaction and administrative efficiency.

Still, we find that organizations struggle with QI. And much of the struggle seems to come from a tendency to look at the “two studies” requirement as something that stands apart from the day-to-day business of providing care to patients.

Imagine that you work in an ASC that specializes in ophthalmology. Your center is performing lots of cataract cases and your goal is to improve visual acuity for your patients. Your center is successful. Business is humming along and patients are happy. Who has time to look around for a topic so that you can submit a couple of QI studies to AAAHC?

Drive quality with systems thinking

What if, instead of thinking about quality as the job of solving problems, you thought of it as the job of finding the next best step? This would be a systems thinking approach that could start by looking at the people, structures, and processes that you have in place (and are probably already measuring in some way) and considering how successfully they work.

Going back to our ophthalmology center, let’s say the cost of Dr. A’s cases and Dr. B’s cases are very similar. Dr. C’s cases, however, cost 15 percent more on average. You know this because your director of nursing is already tracking and reporting this information. Instead of thinking of this as a discrete administrative activity relating to finance, think of it as internal benchmarking.

We know that standardization is an indicator of efficiency, so if two surgical teams are establishing the benchmark, why is the third an outlier? Variations like this can be indicators of opportunities for improvement. Sometimes there are good reasons for variation: perhaps Dr. C’s cases are consistently more complex, taking longer and using more resources. By identifying what makes Dr. C’s cases different, you may find something that can be changed (a corrective action) to yield improvement.

Perhaps s/he uses more than one of an item, a more expensive or larger amount of medication, a more expensive intraocular lens, takes longer to do all cases, or has a slower turn-over time. When change is an option, the impact of that change can be evaluated the next time your administrator reports on the cost of cases. If the change yields improvement, write it up: it’s a QI study.

Benchmarking keeps your organization on the road to quality

Comparison is the essence of benchmarking. You have to understand current performance and desired performance in order to set a realistic goal for improvement. That’s why benchmarking is so important. You may know, based on chart audits, that your primary care patients’ medical records include an update on allergies and untoward reactions 70 percent of the time. Is that good or bad? Internal benchmarking will tell you whether your performance is improving or declining over time, but what about a bigger picture?

Each time you undergo an accreditation survey, you are participating in an external benchmarking activity. Quality
Roadmap, a publication released annually by AAAHC and the AAAHC Institute for Quality Improvement, charts compliance with AAAHC Standards on surveys conducted in the prior year. The report identifies which Standards are most commonly rated partially- or non-compliant by AAAHC surveyors. We look at this in the aggregate across all types of organizations, and also by broad segment (ASC, office-based surgery, primary care).

Make use of AAAHC resources

You can use Quality Roadmap to get a high-level overview of how your organization is performing relative to the Standards that many find challenging. For instance, with the Quality Roadmap in hand, an organization looking at allergy documentation could see that 22 percent of the primary care organizations surveyed had issues with the Standard that relates to this topic (6.F). That means 78 percent of surveyed primary care settings were successful in providing prominent, consistent notes in clinical records regarding reactions to drugs or materials. Based on our hypothetical organization’s 70 percent performance, there’s room for improvement to meet or exceed that external benchmark and an opportunity for a QI study.

And by the way; you don’t have to be accredited to benefit from QI studies! They can help us all to deliver higher quality care.

About the author

Angela FitzSimmons has focused on developing educational resources for customers, particularly relating to quality improvement, since 2011. Prior to joining the AAAHC Marketing and Communications department, she was a consultant serving the organizational development teams for corporate clients including Gap Inc., Kraft and Sara Lee, and the leadership teams of small non-profit education and arts organizations.



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