Complying with Challenging AAAHC Standards

ASCs are expected to comply with accreditation standards not only to achieve and then maintain accreditation, but also, and more importantly, to help improve and better ensure the safe delivery of high-quality patient care. The "AAAHC Quality Roadmap," issued annually by the Accreditation Association for Ambulatory Health Care (AAAHC), is designed to assist with both objectives.

To assemble the 2017 version of the Roadmap, AAAHC analyzed surveyors' ratings of compliance with 2016 AAAHC standards from nearly 1,400 surveys conducted during 2016 and 2017. The report highlights high-deficiency standards for Medicare and non-Medicare deemed status ASCs and other settings, as well as high-compliance standards for AAAHC-accredited organizations.

While the Roadmap speaks specifically to AAAHC standards, it provides insight into possible areas of focus for improvement in any ASC, regardless of its accrediting organization.

Naomi Kuznets, PhD, vice president and senior director for AAAHC's Institute for Quality Improvement, discusses how ASCs can improve their compliance with four areas identified in the Roadmap as particularly challenging.

1. Credentialing and privileging. ASCs consistently struggle to comply with AAAHC credentialing and privileging standards, Kuznets says. "From year to year, we see issues. Credentialing is not just reappointment every three years. It must also take into consideration primary and secondary source verification — making sure the credentials are there throughout the three-year period."

   As for privileging, she says issues center around the need for ASCs to obtain more than a written application for specific privileges. "They need to show the provider is legally and professionally qualified, and that includes obtaining recommendations from peers and peer review."




2. Quality improvement. ASCs often perceive quality improvement (QI) as a much more complicated process than it needs to be, Kuznets says. "Sometimes ASCs don't use the information they are collecting to identify problems for their QI studies. They also need to objectively examine whether an intervention, made as the result of a study, accomplished its intended purpose."




3. Documentation. Many AAAHC accreditation standards mandate some form of documentation. "If you don't have documentation on some processes, it's as if you haven't completed them. This is the way it often works out legally, as well as with accreditation."

   She cites medication reconciliation as one example where ASCs sometimes fall short in meeting documentation requirements. "If that's not documented in the chart, then it never happened. Let's says a patient is released from the ASC and a provider is suggesting the patient discontinue or resume certain medications. This sort of information must be documented."

   Allergy documentation is another example. "This isn't just about whether a patient has an allergy or not, but also the patient's reaction and the severity of the reaction. This information must be updated every time a patient is seen and/or if the patient experiences some new allergy. And it's not just drug allergies. You also need to document food allergies, allergies to substances like latex and environmental allergies, to name a few."

   For charts to be considered complete by AAAHC, ASCs must incorporate information from documents associated with the patient's case into notes in the patient’s record, Kuznets says. "These can include lab reports, operative notes, x-ray readings, and other imaging activities. Sometimes these documents are just included in the chart without any discussion. You need to acknowledge that you have completed and reviewed those activities and incorporate them into the notes."




4. Infection prevention and control. AAAHC expects ASCs to conduct risk assessments for their infection prevention and control (IPC) program, Kuznets says. "Organizations need to look closely at their IPC systems, find out where they might have some weaknesses and then boost up their programs."

   ASCs are expected to use national guidelines, such as those from AORN, the Centers for Disease Control and Prevention or others, to assess their infection prevention and control performance. "To meet our 2018 standards, ASCs will be expected to show surveyors how their infection prevention and control program complies with those standards in practice," Kuznets says.

Strive for Excellence

Kuznets says the Roadmap can serve as one more tool to help ASCs better serve their patients.

"Use it to determine whether your deficiencies are common deficiencies," she says. "If that's the case, you can go to the end of the Roadmap to learn about some of the tools AAAHC offers to help address these deficiencies. Other organizations, such as AORN, also offer resources that can assist your ASC."

If your ASC has an uncommon deficiency, determine the cause, Kuznets says. "Figure out what's going on at your organization that's different from your peers. You can also look to your peers to learn about the best practices they follow to remain compliant."

Note: To download the 2017 AAAHC Quality Roadmap, fill out the form here.

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