AAAHC Quality Roadmap A report on accreditation survey results

Transcription

1 AAAHC Quality Roadmap 2016 A report on accreditation survey results

2 FROM THE AAAHC MEDICAL DIRECTOR This report is a retrospective look at survey results from the prior year. It represents a thorough analysis of data compiled from 13 months (June 2015-June 2016) of completed surveys, and looks at the frequency of partially and non-compliant ratings through several lenses in aggregate and by broad health care setting/organization type. Readers can use this report in several ways. 1. In preparation for an accreditation survey For an organization (or an individual) new to AAAHC, the Accreditation Handbook can be a daunting publication. This document provides hints for where to begin focused efforts. The deficiencies noted are common issues and many (e.g., documentation) are relevant to multiple Standards across several chapters. In addition to identifying the individual Standards and grouping them thematically, we ve included examples of the kind of amplifying comments made by surveyors to help you avoid pitfalls and guide you in your efforts toward compliance. 2. In preparation for a re-accreditation survey For an organization that is readying itself for a triennial on-site survey, this report should be used in conjunction with the most recent survey report. Read together, you can use the two documents to informally benchmark your performance against that of your peers. You may find that you have solved the problems that are commonly identified by surveyors for your type of setting, or you may find it helpful to explore some of the additional resources we identify in section V. (page 9) to preemptively address issues that your preparation has revealed, and to improve your performance on the upcoming survey. 3. As a mid-cycle self-assessment tool AAAHC expects ongoing compliance with the Standards throughout an organization s term of accreditation. This means it s not enough to pick up the AAAHC Accreditation Handbook every three years and rush to make improvements. Use this report as a high-level overview of areas of frequent concern, and the current Handbook as a framework for continuous improvement. Since the first release of this report in 2013, some topics have appeared annually across organizations of all types and sizes. Standards related to documentation and others focused on quality improvement consistently make the list of those with the highest incidence of deficiency. We are focusing on these issues as we retrain our surveyors so that they can be effective consultants when on-site at your organization. We also have placed additional emphasis on these topics in our webinars, at Achieving Accreditation, in new tools, and in our newsletters. Our goal is to help you build a robust library of resources addressing these topics. I invite you to take advantage of them. Sincerely, Jack Egnatinsky, MD AAAHC Medical Director 2

3 I. DESCRIPTION OF THE DATA The information in this report comes from AAAHC surveyors ratings of compliance with our 2015 Standards and their comments describing the nature of any deficiencies found. The data were collected during onsite surveys of organizations seeking initial or re-accreditation, including ambulatory surgery centers in the Medicare Deemed Status program. Results of surveys for organizations seeking accreditation through the AAAHC Health Plan or Federal Employee Health Benefits Plan program are not included. This report includes data collected over 13 months (June 2015-June 2016). It does not include focused surveys those that did not include all core Standards (Chapters 1-8 of the Accreditation Handbook) or those that were the result of a random selection to confirm continued compliance or some required inter-cycle activity. ORGANIZATION TYPES IN THIS REPORT The data points represent 1,363 complete surveys. The chart to the right shows the distribution of surveys for this period by the most commonly self-identified organizational types: ambulatory surgery center (ASC), Medicare Deemed Status ASC (MDS ASC), officebased surgery facility (OBS), and primary care setting (PC). PC includes military, community health, Indian health, occupational health, student health, and other primary care settings. In section III. (page 6), you will find additional data on compliance deficiencies specific to surgical/procedural settings identified as ASC, OBS, or MDS ASC. In section IV., detailed information addresses deficiencies across primary care settings with student health service (SHS) organizations broken out as a distinct group. OBS 11% MDS ASC 25% PC 10% ASC 54% II. OVERALL FINDINGS High compliance Surveyors rate AAAHC Standards as substantially compliant (SC), partially compliant (PC), or non-compliant (NC). For the period of this report, the highest compliance findings (100% rated SC across all organization types) indicate that AAAHC-accredited organizations: n Provide patients with the opportunity to participate in decisions involving their health care. [Standard 1.E (1.N.2)*] n Engage health care professionals who consistently practice their professions in an ethical and legal manner. [Standard 4.B] n Provide information to patients regarding fees for services and payment policies. [Standard 1.F.5-6 (1.I.5-6)] n Have implemented fiscal controls for rates and charges. [Standard 3.A.5 (3.I.B.5)] n Achieve consistency in documentation regarding the person responsible for the patient s care. [Standard 6.C.5 (6.D.5)] For Medicare Deemed Status Surveys, there was strong overall performance with regard to over 200 specific AAAHC/ MDS Standards. * When two Standard identifiers are noted, the first refers to the location of the Standard in the 2015 edition of the Accreditation Handbook for Ambulatory Health Care and the second to the 2015 edition of the Accreditation Handbook for Medicare Deemed Status Surveys. When there is only a single indicator, the Standard is in the same location in both publications. 3

4 Most common deficiencies across organizations While this report looks in depth at those Standards with the highest incidence (10 percent or more) of PC and NC ratings by surveyors, most organizations that seek AAAHC accreditation successfully achieve a three-year term. This year we are focusing on three topics that offer the greatest opportunity for improvement. 25 COMMON DEFICIENCIES II.D 2.II.B.5.b 5.I.C 5.I.A.8 6.F 8.E.3 (5.I.E.6) (5.I.C.8) Credentialing, Privileging, Peer Review QI Program and Studies Documentation 2015 STANDARD IDENTIFIERS Credentialing, Privileging, and Peer Review Credentialing, privileging, and peer review are three separate but related processes. Credentialing means validating a provider s qualifications to offer health care services. Privileging is the process of governing body approval for a provider to deliver specific treatments, procedures, or to use specific equipment. Peer review is the process of confirming a provider s competence by enlisting similarly licensed others to review clinical records and other aspects of care, e.g., infection rates, compliance with medical staff rules and regulations, patient satisfaction surveys. Deficiencies in any of these areas can result in providers who are performing services or procedures for which they need additional qualifications, more experience, and/or performance improvement. These can be immediate threats to patient safety and risk of liability. Newly cited as a high-frequency deficiency this year is Standard 2.II.B.5.b, requiring primary source verification of current state license, DEA registration, medical liability coverage meeting governing body requirements, and NPDB information. This verification, along with a complete reappointment application and results of peer review activities, is considered by the governing body during reappointment. Reappointment must take place every 3 years or more frequently if state or organizational policies so require. Surveyor comments associated with deficiencies for this Standard included: n Peer review was not incorporated into the reappointment process. n Primary source verification was not conducted. n Applications were allowed to expire. Standard 2.II.D consistently appears in this report as a deficiency across organization types. Issues identified by surveyors in citing compliance problems with this Standard included: n Privileges were granted for procedures not provided by the organization. n Delineation of privilege lists were missing signatures or not completed as intended (e.g. check boxes left empty throughout document when these exist to indicate specific privileges). n Delineation of privilege lists were missing specific procedures or privileges for anesthesia administration. n The Medical Director s privileges were not reviewed by another provider. See section V. (page 9) for resources on credentialing, privileging, and peer review. 4

5 Quality Improvement Program and Studies Part of being a high-performing and accreditable organization is commitment to continuous quality improvement. A well-organized quality improvement (QI) program and effective quality improvement studies are key elements. New for this year is Standard 5.I.A.8 (5.I.C.8), the annual review of the organization s quality improvement program for effectiveness and to determine if the program s purposes and objectives continue to be met. Without regularly monitoring the effectiveness of its QI program, an organization does not know whether the program s goals continue to be relevant or whether approaches to the goals should be revisited in general, whether the organization s QI program is on the right track. If an organization is annually (or more frequently) reviewing its QI program, documenting this process demonstrates compliance with the Standard (see Documentation) this page. Standard 5.I.C (5.I.E.6), which addresses quality improvement studies, continues to appear on the list of highfrequency deficiencies across all organization types. The deficiencies here are strongly associated with the lack or inadequacy of a performance goal. If the performance goal is not sufficiently defined and/or not expressed in quantitative terms, it is hard to create a meaningful comparison. What, for example, is the relationship of current performance to the goal? How will you know if a corrective action has had the desired impact? Has the goal already been achieved? To ensure that your goal will meet the requirement, make it SMART. S Specific The goal is clear and easy to understand. It translates into action by using words like increase or decrease. M Measureable The goal is objective and can be assessed by gathering quantitative data, e.g., 25%, 20 minutes, all, none. A Achievable Those responsible for the goal have the knowledge, skills, and resources to deliver the result. R Relevant The goal matches the purpose, e.g., improves compliance, increases patient satisfaction, saves money. T Time-bound The goal has a completion date, e.g., by 12/31, third quarter. See section V. for resources to assist with meeting the AAAHC Standards for quality improvement studies. Documentation Requirements for documentation appear throughout the Standards. A lapse in documentation was touched on in the two preceding sections in the context of credentialing and privileging and annual review of the QI program. Often, an organization has a process to meet the requirement of a Standard, but the process does not include followthrough in the form of written documentation. For many Standards that are applicable to all organizations, written documentation is the primary way for surveyors to confirm that the requirement is being met. From the organizational perspective, documentation offers the benefits of: n Promoting consistency and a means to identify errors or lapses in process. n Assisting in negotiations with payers or liability insurers. n Providing essential back-up should you become involved in litigation. Additional lapses in documentation that met the threshold for high-frequency deficiencies in surveys across all organizations included: n Allergy documentation (6.F). Surveyors note: - Reactions were not documented. - Allergies were not documented in a consistent location. n Written evaluation of emergency drills (8.E) See section V. for resources on allergy documentation and emergency drills. 5

6 III. COMMON FINDINGS IN SURGICAL/PROCEDURAL SETTINGS 20 COMMON STANDARD DEFICIENCIES, SURGICAL/PROCEDURAL SETTINGS (ASC-LEFT; OBS-MIDDLE; MDS ASC-RIGHT) PERCENT DEFICIENCY III.I 9.A 9.F 10.I.C.2 10.I.G 4.E.4 7.I.D.2 7.II.A.3 7.II.O 7.II.P 9.S 11.I 7.II.C (2.III.H) (10.I.H) (7.I.C.2) Credentialing, Privileging, Peer Review Documentation Safe Injection Practices & Medication Safety Education and Training 2015 STANDARD ID (MDS STANDARD ID) In addition to the general findings addressed in section II., additional Standards are cited as partially- or noncompliant with a 10% or greater frequency across surgical settings. For surveys using the 2015 Standards, some of these deficiencies reflect specific issues within themes already identified, specifically privileging, peer review, and documentation. Safe injection practices and ongoing education/training also appeared as areas of concern for surgical/procedural settings. Credentialing, Privileging, and Peer Review As noted in section II., poor credentialing, privileging, and/or peer review practices can lead to immediate threats to patient safety and risk of liability. For Standard 2.III.I (2.III.H), surveyors noted that peer review was not incorporated into the reappointment process. Standards 9.A and 9.F address the provision of anesthesia. Surveyors comments reflected privileging issues, for example: n Anesthesia providers were not granted privileges specific to administering or supervising anesthesia. n Surgeons were not granted privileges for local anesthesia. n RNs were not granted privileges for anesthesia administration. n Surgeons were not granted privileges for supervision. Similarly, Standard 10.I.C.2 addresses privileging for procedures. Surveyors observed: n Privileges were not granted to all providers for all procedures with which they are involved. n Privilege lists did not include all procedures performed by the organization. See section V. (page 9) for resources on credentialing, privileging, and peer review. Documentation As noted in section II., surveyors often rely on documentation to assess whether an organization is compliant with a Standard. Within the organization, documentation provides a means to assess staff adherence (or lack thereof) with policies and procedures and to identify potential opportunities for quality improvement. Additionally, documentation is important to payers and in potential legal proceedings. Surveyor comments on Standard 10.I.G (10.I.H), which focuses on stopping medication prior to surgery and 6

7 resuming medication afterward, appear to center on documentation: n Instructions to resume or stop medications were not documented. n Patient was instructed to stop medications, but instructions for when to resume were not provided. Surveyors cited partial or non-compliance with required medication reconciliation (Standard 4.E.4) for more than 10% of surgical/procedural organizations. This, too, may have been associated with a lack of documentation in clinical records. Medication reconciliation may be part of the organization s process, but for an on-site surveyor relying on documentation, if it wasn t recorded in the patient record, it didn t occur. Standard 7.II.O, covered in greater detail below, also relates to documentation associated with recall policies. Safe Injection Practices and Medication Safety Multiple Standards related to safe injection practices (SIP) and medication safety had high levels of deficiencies this year. Comments related to non-compliance with Standard 7.I.D.2 (7.I.C.2) included: n Multi-dose vials were accessed in patient care areas. (National SIP guideline recommendations are that multi-dose vials be accessed in a clean area, away from patient care.) n The organization s policies were not followed. n USP 797 guidelines (for splitting single-dose vials) were not followed. Surveyor comments on Standard 9.S and 11.I also indicated lack of compliance with SIP guidelines and other safety recommendations: n Multi-dose vials were accessed in patient care areas. n The vials were not wiped with alcohol before being accessed. n Anesthetists carried capped syringes in their pockets. Life-threatening errors can result from using the wrong medication. Surveyors comments regarding non-compliance with Standard 7.II.A.3 were: n A list of look-alike, sound-alike medications was not present. n Pre-drawn medications were not labeled. n Medications with similar names were stored next to each other. Standard 7.II.O addresses product recalls. Recalls can occur due to product contamination, new findings of patient adverse reactions or death, and other reasons. Recalls may effect medications, vaccines, blood/blood products, medical devices, equipment and supplies, and food. Surveyors found: n Recall policies did not include food. n Patient notification was not included in the recall policies. Standard 7.II.P addresses expired medications. Expired medications must be disposed of per manufacturers recommendations, as medication efficacy may change over time. Surveyors noted: n Expired medications were found during the survey. n Expired supplies were found in the crash cart. Education and Training This is a new topic for this report. An important part of maintaining and improving quality is education and training. New staff and providers join the organization, national guidelines change, or staff and providers need sessions to remember/reinforce what they once knew. Training must be sufficiently frequent to ensure staff and providers are up-to-date. Standard 7.II.C requires that medical staff members, allied health providers, employees, volunteers, and others receive safety program education and training and comply with the safety requirements. Surveyors findings regarding non-compliance included the failure of physicians to participate in safety training and failure to provide training with the frequency specified in the organizations own policies. 7

8 IV. COMMON FINDINGS IN PRIMARY CARE AND STUDENT HEALTH SERVICE SETTINGS 20 COMMON STANDARD DEFICIENCIES, PRIMARY CARE & STUDENT HEALTH SETTINGS (PC LEFT/SHS RIGHT COLUMN) 15 PERCENT DEFICIENCY III.I 5.I.C.2 5.II.A 9.E 4.E.8 6.O.1 6.E Credentialing, Quality Improvement and Risk Management Documentation Continuity of Care Privileging, and Peer Review 2015 STANDARD ID In addition to the general findings addressed in section II., additional Standards within those themes saw high (10% or more) levels of deficiencies in Primary Care (PC) and/or Student Health Service (SHS) organizations. Continuity of care was an additional area of concern for these organization types. Credentialing, Privileging, and Peer Review For the student health setting, surveyors noted for Standard 2.III.I that peer review was not incorporated into the reappointment process. Quality Improvement and Risk Management Quality improvement goal setting (5.I.C.2) is an issue for PC overall and SHS specifically. Surveyors comments indicated that: n Goals were not measurable. n Goals were qualitative, not quantitative. Risk management is critical to protect the safety of both patients and employees. For PC organizations, surveyors cited problems with 5.II.A: n Education in risks was not conducted within 30 days of hire. n Education in risks was not conducted annually. n Not all providers received education. Given these comments, deficiencies in Standard 5.II.A might also be considered an issue of ongoing education and training. These are important components of maintaining and improving quality. New staff and providers join the organization, national guidelines change, or staff and providers need sessions to remember and refresh what they once knew. Training must be frequent enough to ensure staff and providers are up-to-date. Standard 5.II.A deficiencies may also be due to documentation error (see below). Documentation As noted in section II., surveyors often rely on documentation to assess whether an organization is compliant with a Standard. Within the organization, documentation provides a means to assess staff adherence (or lack thereof) with policies and procedures and to identify potential opportunities for quality improvement. Additionally, documentation is important to payers and in potential legal proceedings. 8

9 PC organizations had issues with an anesthesia Standard, 9.E, relating to informed consent. Specifically, surveyors found that: n Informed consent was not documented. n Consent forms did not include the risks of the procedure or of the anesthesia. n The surgical consent was present, but there was no anesthesia consent. Continuity of Care Without continuity of care, it is difficult to manage patients chronic diseases and to accomplish the necessary follow-up on prescriptions, test results, and referrals. A significant percentage of PC organizations had issues with Standard 4.E.8, where surveyors found that patients did not have a consistent primary care provider leading to lapses in continuity, and 6.O.1, where surveyors found that information was not obtained from external providers. For SHS organizations, continuity of care issues surfaced at Standard 6.E which requires a summary of diagnoses and procedures for patients with more than 3 visits or a complex/lengthy clinical record. Surveyors found that: n No diagnostic summary was present. n There was no policy for diagnostic summaries. Problems with 6.E may also be considered to be documentation issues (see the previous subsection on Documentation). V. ROADMAP FOR IMPROVEMENT 2017 Use this Report for Benchmarking Your organization can use the data in this report for ongoing self-assessment. Your AAAHC survey report includes comments to explain any PC or NC ratings received by your organization. These should help you to individualize the results of this overview report and to benchmark your survey results. If you have an opportunity for quality improvement, you may want to use some of the following resources for interventions. Patient Safety Toolkit: Allergy Documentation Patient Safety Toolkit: Safe Injection Practices Addressing High-deficiency Themes The AAAHC Institute continues to research and release best-practice tools for patient safety. Among the current titles that address the themes in this report are: AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois Phone: Fax: AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois Phone: Fax: n Allergy Documentation n Credentialing & Privileging n Emergency Drills Patient Safety Toolkit: Peer Review and Benchmarking Patient Safety Toolkit: Credentialing and Privileging n Peer Review & Benchmarking n Safe Injection Practices AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois Phone: Fax: AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois Phone: Fax:

10 2016 A C C R E D I T A T I O N A S S O C I A T I O N for A M B U L A T O R Y H E A LT H C A R E, I N C. Patient Safety Toolkit: Emergency Drills Step 1: Step 3: Step 4: MEDICAL EMERGENCY PRACTICE DRILL CPR/AED USE PROCEDURE CHECKLIST & LINE ASSESS the Internal Emergency and Disaster Preparedness Plan 1. Obtain your organization s internal emergency and disaster preparedness plans and any related organizational policies. 2. Review both the plans and policies: a. Do they address the greatest risks at your organization? Consider geography and type of community organization, e.g., frequency of tornados/rural vs. urban. (See the four bullets under Importance on reverse side.) b. Have you developed a plan for relevant drills (simulations)? c. Do you have a patient evacuation plan? INFORM participants 1. Instruct staff to respond to the drill as if it were a real life emergency. 2. Explain the scenario to the participants (amount of detail is up to the facilitator). 3. Review roles and responsibilities, as necessary. 4. Emphasize the importance of communication with others. 5. Clearly state exceptions such as not pulling the fire alarm, not using a real fire extinguisher, etc. PERFORM the Drill Stage the drill. Have a definitive starting and ending point. For example: n Drill begins when someone yells Help, someone has collapsed! n Drill stops when 4 rounds of CPR with one cycle of the AED have been completed.* * For information on conducting CPR, see the American Heart Association s The Handbook of Emergency Cardiovascular Care for Healthcare Providers AdvancedCardiovascularLifeSupportACLS/The-Handbook-of-Emergency- Cardiovascular-Care-for-Healthcare-Providers_UCM_308747_Article.jsp Date Time Location Patient Collapses First person arrives at the scene (may be first responder-not EMS): - Concern for own safety considered? - Patient checked for responsiveness? - Internal call for help in accordance with emergency protocol - Call 911 command given? - Command given to obtain AED? - Command given to contact First Responder? Time of 911 call (as needed) - Individual sends someone for help? - Individual instructs someone to meet EMS? - Documented emergency protocols followed? Time First Responder arrives at scene (may be a member of staff) - Concern for own safety considered? - Patient checked for responsiveness? - Call 911 and AED commands confirmed? Start Clock Patient Safety Toolkit: Emergency Drills Step 2: Step 5: PLAN for the Drill b. It should be interactive an inservice is not a drill. Actual roles and for example: EVALUATE the Drill c. Identification of problems to address, 1. Schedule a calendar of drills to be behaviors must be practiced. 1. Debrief with participants immediately n Staff did not know where the AED conducted during the year based on the 4. Gather supplies for the drill. For after the drill. Compliment participants was located; CRASH cart had facility risk assessment. example, a CPR drill might include: and make suggestions, if needed. Ask: expired meds. a. List the types of drills and number of n a. A mannequin to represent How do you think it went? Develop a n There was no systematic way times each drill is performed. the patient list of positives and negatives. established to call an emergency. b. Schedule at least one drill from n b. An AED/defibrillator; EKG monitor/ What elements were easy or hard to n Some people did not appear the organization s external disaster pads; stethoscope; oxygen masks remember? to know their roles during the preparedness plan per calendar and tubing; intubation kit; IV n Do you have suggestions to make the emergency. quarter. It is important to note that access supplies; medications (e.g., drill better? n Critical steps, such as calling sufficient frequency is vital to learning intubation, ACLS recommended, 2. Create templates for the written the emergency or calling 911 and retention. 14 and other condition-related and evaluation based on the drill type. immediately, were missed. 2. Develop a tracking method to ensure antagonists)* Templates should include: 3. Develop a corrective action plan from each employee has attended the c. A stop watch to time the response a. The type of drill, date of occurrence this information and set a timeline for required drill for their role. d. A drill evaluation form (see sample) and names of participants conducting another drill and measuring 3. Identify the location and the facilitator(s) * The supplies are dependent on the b. A list of elements required for improvement. of the drill(s). Ensure participants risk factors of the patient (surgical and appropriate management of this type have appropriate training (e.g., BLS, medical), the type(s) of anesthesia of emergency ACLS). Assign specific roles (e.g., used, and the ability of providers to communicator, runner, team leader, carry out their emergency management responder, and documenter) and algorithm (BLS or ALS). Also, check state responsibilities to each participant. 13 requirements, if any exist. a. Create your case-based scenario related to the drill and the organization setting. It may be based on an actual emergency. If an actual emergency (not a false alarm) occurs and your organization implements and documents all components of its associated emergency preparedness plan, including corrective actions, then this may be designated as an emergency drill. Copyright 2014 AAAHC Institute for Quality Improvement (AAAHC Institute). ALL RIGHTS RESERVED. Time of AED command - Patient responsiveness and breathing checked? Time when CPR started - CPR performed correctly? Time of AED arrival at scene - Clothing properly removed? - Electrodes properly placed? - AED voice prompts followed? (especially do not touch patient) Time of first AED shock - AED voice prompts continued to be followed? - Patient placed in recovery position? - Was AED left on? - Monitoring of patient continued? Time of EMS arrival (Add six minutes to time of 911 call) - Were details of event properly conveyed to EMS - Documented emergency procedures followed? SCORING SHOCK WITHIN 3 MINUTES / EMS WITHIN 7 MINUTES EXCELLENT SHOCK WITHIN 5 MINUTES / EMS WITHIN 8 MINUTES FAIR SHOCK AFTER 5 MINUTES / EMS AFTER 8 MINUTES POOR YES ANSWER COUNT = HERO EXTRAORDINAIRE YES ANSWER COUNT = HERO YES ANSWER COUNT = THANKS FOR RESPONDING YES ANSWER COUNT = 6-12 IMPROVEMENT NEEDED YES ANSWER COUNT = LESS THAN 6 POSSIBLE 2nd PATIENT Facility Specific Medical Emergency Protocol Checklist addendum items For further assistance on AED Drills please visit AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois Phone: Fax: Each toolkit incorporates a review of the relevant literature, a description of the importance of the topic to ambulatory health care settings, and a relevant and highly visual tool. Toolkits focus on ambulatory surgery settings, on primary care settings, or are designed for universal applicability. Other topics include checklists, obesity and preventing surgical complications, screening for depression in primary care, Obstructive Sleep Apnea, and pre-operative evaluation. New titles and updated versions of existing toolkits are released regularly. Visit for a comprehensive list and to order. AAAHC Webinars An annual webinar series addresses the findings of this report, among other topics. Visit webinars to review upcoming and archived webinars. Quality Improvement Resources Illuminating Quality Improvement is a comprehensive resource for using data to drive meaningful improvement. This workbook includes tools and worksheets for developing your QI program, collecting and analyzing quality data, using benchmarks to establish goals, and documenting your improvement in alignment with AAAHC Standards. Illuminating Quality Improvement was developed for use at AAAHC Achieving Accreditation programs in facilitator-led small group sessions. This version includes a 12- page Self Study Guide to walk users though each element of the resource. It can be ordered at Innovations in Quality Improvement Compendium is a publication that features AAAHC Institute Kershner Award winning QI studies from 2004 to the present. The Compendium includes detailed abstracts of these exemplary studies with commentary about how each element of the AAAHC Standards is met. Using Benchmarking Measurement to Improve Performance over Time is a case study illustrating the use of benchmarking within a QI study. This resource is available free of charge at Whitepapers--/ Q Q Q I L L U M I N A T I N G Q U A L I T Y I M P R O V E M E N T Q 10

11 IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION Seminars Achieving Accreditation is a quarterly seminar that provides intensive review of the Standards and special topics related to accreditation. Upcoming programs for 2017 are scheduled for: March 17-18, Tampa, Florida June 23-24, San Diego, California September, TBD (check for updated information) December 1-2, Las Vegas, Nevada AAAHC Newsletters Triangle Times is a quarterly print publication sent to all accredited organizations and by subscription request. Most issues include Standard Bearer, a column focused on the intent and interpretation of an individual Standard with hints for compliance. Past issues can be reviewed at Connection is a bi-monthly e-newsletter sent on request to subscribers. Each issue focuses on a single topic related to improving the quality of your ambulatory health care organization. Past issues can be reviewed at Volume 3 Issue 3 Summer 2016 associated with health care settings. But at Premise Health, these are deliberate choices designed to reinforce a culture of engagement, keeping staff members connected, loyal, and July 2016 committed to their mission of helping people get, stay and be well. Upcoming Webinars Based in Brentwood, Tenn., Premise Health is a leading health Building and patient a engagement robust company that manages more credentialing, than 500 worksite-based privileging, health and and wellness centers across peer the country, review serving process over 200 of the nation s leading employers. July 13 We deliberately designed our corporate environment to Creating an "Aha" moment in encourage communication among team members, said Liz Reimer, quality chief human improvement resources officer at Premise Health. It enhances September the flow of 14information and teamwork, making it Want more on Informed Consent? Watch for an announcement of a November 2 webinar. Education programming in DC this fall Achieving Accreditation will be picturing excellence September at the Marriott Marquis, Washington DC Informed consent The AAAHC program is for surgical and primary care Informed consent is the name given to the idea organizations. Register here. that a patient has a legal and ethical right to direct A concurrent AAHHS-HFAP program is for acute care what happens to his/her body. Even though the hospitals (with separate health term specifically appears in a limited number of care and physical environment AAAHC Standards* it is the philosophical basis for tracks) and laboratories. Register here. positioning patient rights first among the Come meet the family and learn requirements for accreditation. the whole range of programs we offer! The goal of informed consent is that a patient has the opportunity to be an active participant in his/her health care Chapter 17: Behavioral decisions. This means that the provider has a responsibility to Health Services disclose the nature of the proposed treatment or procedure, Revised Standards for the relevant associated risks, and any options along with the behavioral health services were approved by the AAAHC board attendant risks of those alternatives. after publication of the 2016 handbook. The new Standards These disclosures represent only the first (and perhaps the become effective for surveys simplest) step in a process. There is often an inherent power taking place on or after August imbalance in the provider-patient relationship that can easily 1, A newsletter of the Accreditation Association for Ambulatory Health Care, Inc. When collaboration becomes more than a concept Entering the corporate office, you might think you were at a high tech start-up: the creative casual dress code, the ping pong table, and the variety of shared spaces designed with group gatherings in mind these attributes aren t usually continued on page 4 11

12 5250 Old Orchard Road, Sts. 200 & 250 Skokie, Illinois Copyright 2016 AAAHC and AAAHC Institute for Quality Improvement (AAAHC Institute). ALL RIGHTS RESERVED.