AAAHC Quality Roadmap A report on accreditation survey results

AAAHC Quality Roadmap 2017 A report on accreditation survey results

FROM THE AAAHC PRESIDENT AND CEO The AAAHC Quality Roadmap is a retrospective report which presents a thorough analysis of data from nearly 1,400 surveys conducted during the prior year using the 2016 Standards. This valuable tool identifies themes that deserve special attention by organizations in their continuous pursuit of quality improvement throughout the accreditation cycle. In this way, we can learn from each other and take corrective action as necessary. As the new President and CEO of AAAHC, it is my pleasure to provide this information as a resource to our accredited organizations. Our goal is to increase your understanding of AAAHC Standards and provide useful benchmarks to help your organization improve the quality of care you provide to patients. While the report indicates that most facilities surveyed are in compliance with the majority of Standards, it also includes a number of focus areas for improvement that warrant your attention. We continue to see that facilities are having challenges with quality improvement studies, credentialing and privileging, and documentation management. We welcome your feedback on how we can assist you in better understanding the Standards and building compliance into the fabric of your quality improvement and assurance plans. AAAHC Quality Roadmap presents data that is actionable and should be used as a tool for: Comparing these findings to your last onsite survey report and your annual self-assessment Understanding the most common deficiencies relevant to your setting Reviewing policies, procedures, and practices to ensure they reflect best practices and relevant AAAHC Standards Leveraging patient safety toolkits and other resources available from AAAHC to improve and assure quality Sharing and discussing the findings with others within your organization to drive decision-making on QI studies or other corrective action that may be necessary Please take the opportunity to look more closely at these 2016 survey findings and take advantage of our broad portfolio of educational programs and quality improvement resources that AAAHC offers to help you comply with our best practice Standards not just on the day of your survey but throughout your accreditation term. Sincerely, Noel Adachi, MBA President and CEO I. DESCRIPTION OF THE DATA The information in this report comes from surveyors ratings of compliance with 2016 AAAHC Standards. The data were collected during onsite surveys of organizations seeking initial or re-accreditation, including ambulatory surgery centers in the Medicare Deemed Status program. For these organizations, we also included frequent deficiencies related to CMS Conditions for Coverage. Results of surveys for organizations seeking accreditation through the AAAHC Health Plan or Federal Employee Health Benefits Plan program are not included. This report also does not include intra-cycle surveys. Often, these are focused surveys that do not include all core Standards (Chapters 1-8 of the Accreditation Handbook). PC 9% OBS 11% MDS ASC 21% ORGANIZATION TYPES IN THIS REPORT Other 2% ASC 57% The data represent 1,385 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), office-based surgery facility (OBS), primary care setting (PC), and Other. Primary care settings include military, community health, immediate/urgent care, Indian health, occupational health, student health, and other primary care settings. Other includes dental practices, diagnostic imaging centers, freestanding emergency centers, medical group practices, and office-based anesthesia practices. 2

Under the 2016 Handbooks, surveyors describe organizational performance against the AAAHC Standards as substantially compliant (SC) [compliant (C) for MDS Surveys], partially compliant (PC), or non-compliant (NC). For the purposes of this report, we are reporting on the highest and the lowest compliance findings. 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. Additional data on compliance deficiencies specific to surgical/procedural settings identified as ASC, OBS, or MDS ASC are contained in Section III (page 5) below. Section IV provides detailed information on deficiencies across primary care settings with student health service (SHS) organizations separated as a distinct group. An analysis of the highest Patient Centered Medical Home (AAAHC Accreditation Handbook Chapter 25) Standards is also included in Section IV. II. OVERALL FINDINGS High Compliance Standards For the period of this report, the highest compliance findings (100% rated SC across all non-mds organization types or 100% rated C across all MDS organization) indicate that AAAHC-accredited organizations demonstrate compliance with the following Standards: Non MDS Standard 1.E 1.F.3 3.A.7 & 3.A.12 6.C.1 Language Patients are given the opportunity to participate in decisions involving their health care, except when such participation is contraindicated for medical reasons. Information is available to patients and staff concerning: Services available at the organization. Administrative policies, procedures and controls are established and implemented to ensure the orderly and efficient management of the organization. Administrative responsibilities include, but are not limited to: (7) controlling the purchase, maintenance, and distribution of the equipment, materials, and facilities of the organization and (12) dealing with inquiries from governmental agencies, attorneys, consumer advocate groups, and the media. An individual clinical record is established for each person receiving care. Each record includes, but is not limited to: name. MDS (Numbers in brackets are Conditions of Coverage Requirements) Standard Language 2.I.C The organization is a legally constituted entity, or an organized sub-unit of a legally constituted entity, or is a sole proprietorship in the state(s) in which it is located and provides services. 2.I.D The ASC must comply with state licensure requirements. [416.40] The ASC must have an effective procedure for the immediate transfer, to a hospital, of patients requiring emergency 2.I.J.1 medical care beyond the capabilities of the ASC. [416.41(b)(1)] 1. This hospital must be a local, Medicare-participating hospital or a local, nonparticipating hospital that meets the requirements for payment for emergency services under Title 42 CFR 482.2. [416.41(b)(2)] 3.I.B.11 & 12 3.II.B.1 3.II.H.4.b 3.II.K 4.E.4 & 5 6.C.2 6.D.1, 3 & 4 Administrative policies, procedures and controls are established and implemented to ensure the orderly and efficient management of the organization. Administrative responsibilities include, but are not limited to: (11) maintaining a health information system that supports the collection, integration, and analysis of data and allows reporting as necessary and (12) dealing with inquiries from governmental agencies, attorneys, consumer advocate groups, and the media. Nursing services of the Ambulatory Surgery Center is directed under the leadership of a Registered Nurse. [416.46]: 1. The nursing service of the ASC assures that all nursing needs of all patients are met. [416.46] The organization has an effective program addressing bloodborne pathogens, including: Post-exposure evaluation and treatment. Records of work injuries and illnesses are maintained, consistent with reporting requirements, and employee health records are managed appropriately. The organization facilitates the provision of high-quality health care by: (4) providing treatment consistent with clinical impression or working diagnosis and (5) making appropriate and timely consultation and referrals. A designated person is in charge of clinical records. This person's responsibilities include, but are not limited to: The timely retrieval of individual records upon request. An individual clinical record is maintained for each person receiving care. [416.47(b)] Every record must be accurate, legible, and promptly completed. Each record includes at least the following: (1) name; (3) date of birth; (4) gender. 3

6.H Documentation regarding missed and canceled appointments is added to the patient's record. 7.II.F Personnel trained in the use of emergency equipment and in cardiopulmonary resuscitation must be available whenever there is a patient in the ASC. [416.44(d)] 10.I.L.1 & 2 10.I.P.1 10.I.T.2 11.L LSC.3.15 LSC.8.34 Whenever patients are present in the facility, the organization ensures that: 1. Health care professionals trained in the use of emergency equipment and basic life support (BLS) are present and 2. At least one physician or dentist is present or immediately available by telephone. If procedures performed pose the risk that blood loss may require blood replacement, the organization must have written policies and procedures to address this situation. [416.48(a)(2)] 1. If the organization performs procedures where blood loss and subsequent blood replacement is a potential, blood and blood products must be administered by only physicians or registered nurses. [416.48(a)(2)] During the pre-procedure time out, the following items are verified: intended procedure. Providers or other health care professionals who prescribe, dispense, administer, and provide patient education on medications have easy access to current drug information and other decision support resources. The maximum distance between any point in an occupiable room and the nearest exit door (into a rated enclosure, or direct to the exterior) is no greater than 150 feet, except in buildings fully protected by an approved automatic sprinkler system, where the distance is limited to 200 feet. The EES provides alternate power for Life Safety branch loads with a minimum duration of 90 minutes. High Deficiencies The following findings are for the 1,099 non-mds organizations surveyed under the 2016 AAAHC Standards. These include Standards rated as deficient at least 10% of the time, as a percent of all ratings for the Standard. These overall results reflect past years findings, including: credentialing and privileging, documentation, quality improvement, and patient safety/safe injection practices. 2.II.B.5.b 13 Members of the medical or dental staff must apply for reappointment every three years, or more frequently if state law or organizational policies so stipulate. The reappointment process includes: Upon receipt of the completed reappointment application, the organization will conduct primary or secondary source verification of items listed in Standard 2.II.B.3.c-f. At the time of reappointment consideration by the governing body, the entire reappointment application and peer review results and activities, completed in accordance with Chapter 2.III, will be considered. 2.II.D 17 Privileges to carry out specified procedures are granted by the organization to the health care professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. These privileges are granted based on an applicant s written request for privileges, qualifications within the services provided by the organization and recommendations from qualified medical or dental personnel. 2.III.I 11 The results of peer review are used as part of the process for granting continuation of clinical privileges, as described in Chapter 2.II. 4.E.4 13 The organization facilitates the provision of high-quality health care by: performing medication reconciliation. 5.I.C 12 The organization demonstrates that ongoing improvement is occurring by conducting quality improvement studies when the data collection processes described in Standard 5.I.B indicate that improvement is or may be warranted. Written descriptions of QI studies document each of the following elements, as applicable. 5.I.C.8 10 Re-measurement (a second round of data collection and analysis as described in Standard 5.I.C.4-6) to objectively determine whether the corrective actions have achieved and sustained demonstrable improvement. 6.F 15 The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistently defined location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified. 7.I.B.4 10 The written infection prevention and control program is: The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization. 7.I.D.2 13 The infection prevention and control program reduces the risk of health care-acquired infection as evidenced by education and active surveillance, consistent with: CDC or other nationally-recognized guidelines for safe injection practices. 4

8.E 11 The organization conducts scenario-based drills of the internal emergency and disaster preparedness plan. 11.I 12 The organization must have policies in place for safe use of injectables and single use syringes and needles that, at minimum, include CDC or comparable guidelines for safe injection practices. 18 PERCENT DEFICIENCY ( 10) ALL NON-MDS ORGANIZATIONS 16 14 12 10 8 6 4 2 0 2.II.B.5.b 2.II.D 2.III.I 4.E.4 5.I.C 5.I.C.8 6.F 7.I.B.4 7.I.D.2 8.E 11.I Credentialing & Privileging Documentation Quality Improvement Patient Safety/Safe Injection Practices III. COMMON FINDINGS IN SURGICAL/PROCEDURAL SETTINGS Non-MDS ASCs Since ASCs comprise the majority of non-mds organizations surveyed under the 2016 Standards, these results are not, surprisingly, nearly identical to the results in the previous section. The exceptions are 6.J and 10.I.G, two additional documentation issues, with the latter also having a patient safety component. 2.II.B.5.b 14 Members of the medical or dental staff must apply for reappointment every three years, or more frequently if state law or organizational policies so stipulate. The reappointment process includes: Upon receipt of the completed reappointment application, the organization will conduct primary or secondary source verification of items listed in Standard 2.II.B.3.c-f. At the time of reappointment consideration by the governing body, the entire reappointment application and peer review results and activities, completed in accordance with Chapter 2.III, will be considered. 2.II.D 18 Privileges to carry out specified procedures are granted by the organization to the health care professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. These privileges are granted based on an applicant s written request for privileges, qualifications within the services provided by the organization and recommendations from qualified medical or dental personnel. 2.III.I 12 The results of peer review are used as part of the process for granting continuation of clinical privileges, as described in Chapter 2.II. 4.E.4 14 The organization facilitates the provision of high-quality health care by: performing medication reconciliation. 5.I.C 12 The organization demonstrates that ongoing improvement is occurring by conducting quality improvement studies when the data collection processes described in Standard 5.I.B indicate that improvement is or may be warranted. Written descriptions of QI studies document each of the following elements, as applicable. 5.I.C.8 11 Re-measurement (a second round of data collection and analysis as described in Standard 5.I.C.4-6) to objectively determine whether the corrective actions have achieved and sustained demonstrable improvement. 6.F 14 The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistently defined location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified. 5

6.J 11 7.I.D.2 14 10.I.G 11 11.I 12 Reports, histories and physicals, progress notes, and other patient information (such as laboratory reports, x-ray readings, operative reports, and consultations) are reviewed and incorporated into the record, as required by the organization s policies. The written infection prevention and control program is: The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization. Specific instructions for discontinuation or resumption of medications prior to and after a procedure are provided to the patient with corresponding documentation in the patient s clinical record. The organization must have policies in place for safe use of injectables and single use syringes and needles that, at minimum, include CDC or comparable guidelines for safe injection practices. 18 16 14 12 10 8 6 4 2 0 PERCENT DEFICIENCY (>10) NON-MDS ASC 2.II.B.5.b 2.II.D 2.III.I 4.E.4 5.I.C 5.I.C.8 6.F 6.J 7.I.D.2 10.I.G 11.I Credentialing & Privileging Documentation Quality Improvement Patient Safety/Safe Injection Practices MDS ASCs Note: for this analysis, Standards rated as deficient on at least 19% of the surveys were identified. Please note that 2.II.D and 7.I.C.2 (the equivalent of 7.I.D.2 for non-mds) are seen in other organizations as well. 7.I.C.2 deficiencies were seen at 19% for MDS ASCs. The medication reconciliation deficiency (11.M) has previously been an issue for this group of organizations. The remaining issues are related to Life Safety Code (LSC) or other Centers for Medicare and Medicaid (CMS) associated Deemed Status Standards. 2.I.H.12.f 96 2.II.D 23 7.I.C.2 19 8.A.4 96 11.M 20 Governing body responsibilities include at a minimum: Approving and ensuring compliance of all major contracts or arrangements affecting the medical and dental care provided under its auspices and ensuring that services are provided in a safe and effective manner, including, but not limited to, those concerning: The Centers for Medicare & Medicaid Services (CMS) requirements. Privileges to carry out specified procedures are granted by the organization to the health care professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. These privileges are granted based on an applicant's written request for privileges, qualifications within the services provided by the organization and recommendations from qualified medical personnel. [416.45(a)] The infection control and prevention program reduces the risk of health care-acquired infection as evidenced by education and active surveillance, consistent with: CDC or other nationally-recognized guidelines for safe injection practices. The organization provides evidence of compliance with the following: Except as otherwise provided in this section, the ASC must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served, and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4). [416.44(b)(1)] If look-alike or sound-alike medications are present, the organization identifies and maintains a current list of these medications, and actions to prevent errors are evident. 6

LSC.8.13 23 All receptacles in patient care spaces are tested as follows: Visual inspection to confirm physical integrity The continuity of the grounding circuit for each receptacle is verified The correct polarity of hot and neutral connections for each receptacle is verified The retention force of the grounding blade of each receptacle is tested and verified to be at least 4 oz. Hospital grade receptacles are tested immediately following installation, servicing, and replacement LSC.8.17 31 Emergency and Standby Power System (EPS) equipment (generator set) is selected, located, installed, and maintained in full compliance with the 2010 edition NFPA 110, including but not limited to the following: The generator set is located in a room dedicated to EES equipment and is separated from the remainder of the building by construction with a minimum 2-hour fire rating or is located in an exterior enclosure (or fixed housing integral with the generator set) capable of preventing the entrance of snow or rain and resisting high wind speeds. EPS equipment and separate Stored Emergency Power Supply System (SEPSS) equipment may occupy the same interior space. The locations housing EPS equipment are located to minimize the possibility of damage from flooding, including that from firefighting, sewer or storm water backup, and similar adverse events or consequences. Interior EPS locations provide at least 36-in. working clearance on all sides as necessary to accommodate inspection, testing, or maintenance activities. Clearances are measured from the skid rails greatest extension in the direction of access. The EPS is heated as necessary to maintain water jacket temperatures specified by the manufacturer. Interior locations of EPS equipment are provided with adequate tempered airflow to assure the room does not exceed EPS manufacturer-specified temperature ranges when standing by or while running at rated load. LSC.12.8 32 Doors in fire-rated construction are protected as required for the fire resistance of the barrier in which they occur, as follows: Doors in rated assemblies are self-closing and close with a positive latch when released from any position. If a rated door is held open, it is by a device that will automatically release it upon activation of an automatic sprinkler system, upon activation of the smoke and/or fire alarm system, and upon loss of power to the hold-open device. Doors in stair/exit enclosures that are held open will automatically close upon activation of a smoke detector, upon loss of power to the hold-open device, or when manually pulled away from the holdopen device. The release of any door in an exit enclosure by a smoke detection device automatically releases all doors held open serving all floor levels from the same stair. Fire-rated door assemblies consist of labeled (with fire rating) frames and labeled doors, with or without labeled vision panels. The rating of the overall assembly is determined by the lowest labeled component (door, frame, or vision panel). All fire rated doors assemblies are visually inspected at least annually for signs of wear, damage, or other condition that could impair their performance and/or reliability. Such inspection is performed by individuals with demonstrated knowledge and understanding of the requirements and functional components of the rated assemblies being evaluated, and includes: Door and door hardware function and physical integrity Condition of both door faces and swing/access clearances on both sides Space on both sides of the door and the finished floor surface The maximum gap between the closed door and frame jambs and top and/or between the strike side edges of pairs of doors (as applicable) Each door s opening force and closing speed Fire-rated doors and windows that are no longer in use have been removed and replaced by wall assemblies with fire/smoke resistive rating at least equal to the wall or assembly in which they occur Repairs, adjustments, and/or other corrections are made without delay upon identification. 7

100 90 80 70 60 50 40 30 20 10 0 PERCENT DEFICIENCY ( 19) MDS ASC 2.I.H.12.f 2.II.D 7.I.C.2 8.A.4 11.M LSC.8.13 LSC.8.17 LSC.12.8 Life Safety Code or CMS Deemed Status Specific Standard Credentialing & Privileging Safe Injection/Medication Practices Office-Based Surgery The findings here are similar to those previously identified in other settings with additional difficulties with: benchmarking a formal, documented infection prevention and control program cleaning, disinfection, and sterilization of medical equipment per manufacturers instructions monitoring/disposal of expired products (medications, reagents, solutions, and supplies) that have a manufacturer s printed expiration date in compliance with facility policy and manufacturers guidelines completing a written evaluation of emergency drills 2.II.D 17 Privileges to carry out specified procedures are granted by the organization to the health care professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. These privileges are granted based on an applicant s written request for privileges, qualifications within the services provided by the organization and recommendations from qualified medical or dental personnel. 4.E.4 15 The organization facilitates the provision of high-quality health care by: performing medication reconciliation. 5.I.B.4 11 The organization implements data collection processes to ensure ongoing quality and to identify qualityrelated problems or concerns. Such processes include, but are not limited to: Comparison of the organization s performance to internal and external benchmarks. 5.I.C 12 The organization demonstrates that ongoing improvement is occurring by conducting quality improvement studies when the data collection processes described in Standard 5.I.B indicate that improvement is or may be warranted. Written descriptions of QI studies document each of the following elements, as applicable. 5.I.D 11 The organization participates in external benchmarking activities that compare key performance measures with other similar organizations, with recognized best practices, or with national or professional targets or goals. 6.F 15 The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistently defined location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified. 7.I.B.4 12 The written infection prevention and control program is: The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization. 7.I.D.2 14 The infection prevention and control program reduces the risk of health care-acquired infection as evidenced by education and active surveillance, consistent with: CDC or other nationally-recognized guidelines for safe injection practices. 7.I.F.2 12 Processes for the cleaning, disinfection, and sterilization of instruments, equipment, supplies, and implants adhere to: manufacturer s instructions for use. 7.II.Q 11 Products, including medications, reagents, solutions, and supplies that have a manufacturer s printed expiration date are monitored and disposed of in compliance with facility policy and manufacturer s guidelines. 8.E 15 The organization conducts scenario-based drills of the internal emergency and disaster preparedness plan (especially E.3: A written evaluation of each drill is completed). 11.I 14 The organization must have policies in place for safe use of injectables and single use syringes and needles that, at minimum, include CDC or comparable guidelines for safe injection practices. 8

18 16 14 12 10 8 6 4 2 0 PERCENT DEFICIENCY (>10) FOR OBS 2.II.D 4.E.4 5.I.B.4 5.I.C 5.I.D 6.F 7.I.B.4 7.I.D.2 7.I.F.2 7.II.Q 8.E 11.I Credentialing & Privileging Documentation Quality Improvement/Benchmarking Patient Safety/Infection Control and Prevention IV. COMMON FINDINGS IN PRIMARY CARE AND STUDENT HEALTH SERVICE SETTINGS Primary Care (PC) Organizations Primary care findings reflect Standards rated as deficient on at least 15% of the surveys. In common with other groups, primary care organizations had deficiencies in credentialing and privileging (2.II.D), allergy documentation (6.F), and emergency drills (8.E). This group has explicit issues with: Quality Improvement Study (Standard 5.I.C) Element 6 (comparing performance versus goals) a formal, documented infection prevention and control program an assigned infection prevention and control professional with appropriate training and credentials anesthesia supervision documentation of pathology findings Please also note that Standard 7.I.D.2 (Safe Injection Practices) was rated as deficient on 7.2% of these surveys. 2.II.D 15 Privileges to carry out specified procedures are granted by the organization to the health care professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. These privileges are granted based on an applicant s written request for privileges, qualifications within the services provided by the organization and recommendations from qualified medical or dental personnel. 5.I.C.6 15 The organization demonstrates that ongoing improvement is occurring by conducting quality improvement studies when the data collection processes described in Standard 5.I.B indicate that improvement is or may be warranted. Written descriptions of QI studies document each of the following elements, as applicable: a comparison of the organization s current performance in the area of study against the previously identified performance goal. 6.F 18 The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistently defined location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified. 7.I.B.4 21 The written infection prevention and control program is: The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization. 7.I.C 16 The infection prevention and control program is under the direction of a designated and qualified health care professional who has training and current competence in infection control. 8.E 22 The organization conducts scenario-based drills of the internal emergency and disaster preparedness plan (especially E.1: At least one drill is conducted each calendar quarter). 9.C 15 The organization ensures the appropriate supervision of anesthesia services. 10.I.L 18 With the exception of those exempted in writing by the governing body after medical review, tissues removed during surgery are examined by the pathologist, whose signed report of the examination is made a part of the patient s clinical record. 9

25 PERCENT DEFICIENCY ( 15) PC 20 15 10 5 0 2.II.D 5.I.C.6 6.F 7.I.B.4 7.I.C 8.E 9.C 10.I.L Credentialing & Privileging Documentation Quality Improvement/Benchmarking Patient Safety/Infection Control and Prevention Student Health Services (SHS) The following results are from 55 SHS surveys under the 2016 AAAHC Standards. As SHS comprise a substantial proportion of primary care organizations, these results have several similarities to the larger primary care group. SHS also had compliance issues with Standards regarding: primary and secondary source verification of credentials evaluation of QI programs at least annually goal setting for QI studies documenting education on risk management documenting infection prevention and control risk assessment placing sharps containers in appropriate areas conducting emergency drills at least quarterly 2.II.B.5.b 11 2.II.D 18 5.I.A.8 13 5.I.C.2 11 5.II.E 11 Members of the medical or dental staff must apply for reappointment every three years, or more frequently if state law or organizational policies so stipulate. The reappointment process includes: Upon receipt of the completed reappointment application, the organization will conduct primary or secondary source verification of items listed in Standard 2.II.B.3.c-f. At the time of reappointment consideration by the governing body, the entire reappointment application and peer review results and activities, completed in accordance with Chapter 2.III, will be considered. Privileges to carry out specified procedures are granted by the organization to the health care professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. These privileges are granted based on an applicant s written request for privileges, qualifications within the services provided by the organization and recommendations from qualified medical or dental personnel. The organization has a written quality improvement program for ensuring ongoing quality and improving performance when needed. The program is broad in scope in order to address clinical, administrative, and cost-of-care performance issues, as well as actual patient outcomes, i.e., results of care, including safety of patients. At a minimum, the written program: Is evaluated at least annually for effectiveness and to determine if the program s purposes and objectives continue to be met. The organization demonstrates that ongoing improvement is occurring by conducting quality improvement studies when the data collection processes described in Standard 5.I.B indicate that improvement is or may be warranted. Written descriptions of QI studies document each of the following elements, as applicable: Identification of the measurable performance goal against which the organization will compare its current performance in the area of study. The goal must be stated in quantitative terms. Documented education regarding the risk management program, policies, and activities including adverse incident reporting, is provided to all staff within 30 days of beginning employment, annually thereafter, and when there is an identified need. 10

After performing a risk assessment (see 1. RISK ASSESS...), use the process below to assist in designing a SIP training program. To ensure provider competency, training should occur at least annually and should include scenario-based examples. PRACTICE Aseptic Routine READ Medication Container Do providers clean hands with alcohol-based sanitizer or with soap and water prior to accessing supplies and preparing and administering injections? Do providers wear a facemask if placing a catheter or 6, 7, a injecting material into the epidural or subdural space? Is the medication stored and prepared in a designated area CHECK separate from the patient care area? Storage/Medication Is the area clean? A clean area allows preparation of injections Preparation using aseptic technique and is free from contact with blood, body fluid or contaminated equipment. Is it the correct medication and strength? Be aware of lookalike/sound-alike drugs. Is the type of container (e.g. single dose vial, multi-dose vial) identified on the label? Don t assume you can determine the Is the expiration date on the label? Does the vial appear free of contaminants? NO NO NO NO / UNSURE PROVIDE ADDITIONAL TRAINING. PROVIDE ADDITIONAL TRAINING. PROVIDE ADDITIONAL TRAINING. DISCARD and go back to designated clean area to look for unexpired medication. a See APIC s January 2016 Position Paper: Safe injection, infusion, and medication vial practices in health care for additional information on the use of aseptic technique. 7 b In addition, all intravenous bags, tubing, and connectors are considered single-use items i.e., for use on one patient and one patient only. Once used, these items must be appropriately discarded. 6 c Beyond-use-date should appear only on previously used MDV and is defined as 28 days after the initial entering of the MDV unless otherwise specified by the manufacturer. Is this a single-dose vial (SDV)? An SDV is approved for use on only one patient 1. DISINFECT the rubber septum on all vials using 70% alcohol prior to each entry, even after initially removing the cap of a new, unused vial. 2. WITHDRAW* medication using new, sterile needle and syringe. Remember: One Needle, One Syringe, One Patient. 3. ADMINISTER medication to patient. 4. DISCARD medication vial, syringe, and needle into an appropriate disposal Is this a multi-dose vial (MDV)? An MDV has an FDA-approved label indicating that it is an MDV and can be used for more NO than one patient when all SIP are followed. However, to add an extra layer of protection, 1. DISINFECT the rubber septum on all vials using 70% alcohol prior to each entry, even after initially removing the cap of a new, unused vial. 2. WITHDRAW* medication using new, sterile needle and syringe in designated clean area. Remember: One Needle, One Syringe, One Patient. 3. LABEL THE VIAL (if this is the initial access) with a beyond-use-date which is 28 days after initially entering the vial unless otherwise specified by the manufacturer. NOTE: The 4. LABEL THE SYRINGE using labels provided by the pharmacy or medication manufacturer, if available. If creating a label, include the date and time of draw, initials of the person drawing, medication name, strength, and discard date and time; and make sure it does 5. LEAVE any unused medication remaining in the MDV in the designated clean area. 6. ADMINISTER medication to patient. 7. DISCARD syringe, and needle, including any prefilled, unused needles/syringes which have been in the patient care area, into an appropriate disposal container (e.g., sharps container). h * Recommendations on storing syringes with medication drawn from a SDV or MDV: CDC recommends preparing injections as close as possible to the time of administration to the patient. This is to prevent compromised sterility (i.e., microbial contamination) or compromised physical and chemical stability (e.g., loss of potency, adsorption to the container) of the medication when it is transferred outside of its original container and stored for a period of time before administration. It is recommended that health care providers adhere to USP 797 "immediate-use" guidelines and administer pre-drawn syringes within 1 hour and/or adhere to manufacturers instructions (For example, pre-drawn syringes of propofol should be administered within 12 hours). NO Is the medication in manufactured pre-filled syringes? Remember: One Needle, One Syringe, One Patient. 1. ADMINISTER medication to patient. 2. DISCARD syringe, and needle including any prefilled, unused needles/syringes which have been in the patient care area into an appropriate disposal container (e.g., sharps container). d SDVs do NOT contain an antimicrobial preservative and thus, once opened, are at risk of growing single procedure, it should be with a new needle and new syringe. The septum must be wiped with 70% alcohol again, and the vial must be discarded at the end of the procedure, i.e., NOT stored for preservatives DO NOT protect against bloodborne viruses such as Hepatitis B, Hepatitis C, and HIV. If an MDV is to be used for more than one patient, the vial cannot enter the patient care area (e.g., operating room or anesthesia cart). If this occurs the MDV must be used for a single patient and discarded immediately after use. 20 g The ONLY time a syringe does not have to be labeled is when an unopened MDV is on an anesthesia cart and upon entering the MDV, it is immediately injected into the patient. If filling multiple syringes for use throughout a procedure, each syringe MUST be labeled and the MDV and any remaining filled needles/syringes MUST be discarded after the procedure. h If the multi-dose or multi-use vial will be entered more than once for either a single patient or for more than one patient, ALWAYS use a new sterile syringe and new needle when entering the vial. Also, remember to disinfect the rubber septum with 70% alcohol on the vial prior to each additional entry. This toolkit is designed only to raise awareness of the research and issues of Safe Injection Practices (SIP). The information provided in this toolkit should not be relied upon as meeting any specific legal, regulatory or clinical requirements nor should it be used as a substitute for clinical judgment. Additional copies for personal/internal use may be ordered from the AAAHC Institute website: www.aaahc.org/institute. Copyright 2017 AAAHC Institute for Quality Improvement (AAAHC Institute). ALL RIGHTS RESERVED. 6.F 15 7.I.B.4 16 7.I.G.3 13 8.E 20 The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistently defined location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified. The written infection prevention and control program is: The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization. A written sharps injury prevention program must be present in the organization. Such a program will include: Placement of sharps containers in appropriate care areas, secured from tampering. The organization conducts scenario-based drills of the internal emergency and disaster preparedness plan (especially E.1: At least one drill is conducted each calendar quarter). Patient Centered Medical Home Sixty-two (62) organizations were evaluated under the 2016 Patient Centered Medical Home Standards (AAAHC Accreditation Handbook Chapter 25). The highest deficiency Standards (greater than 20% deficiencies) were the following. A.3 27 Patients are provided with information and explanation regarding the Medical Home approach to care. A.16 23 The Medical Home provides services within a team framework, and that team provider concept has been conveyed to the patient. C.2.f 31 The Medical Home scope of service includes, but is not limited to: Documented discussions regarding endof-life or palliative care, as appropriate. E.6 34 In addition to the Standards presented in Chapter 5.I, the Medical Home s quality improvement program includes at least one study every three years on each of the following topics: especially 6.a. patient/primary care provider relationship and 6.b. accessibility to care. F 25 Electronic data management is continually assessed as a tool for facilitating the Standards above. V. ROADMAP FOR IMPROVEMENT 2018 Use this Report for Benchmarking Your organization can use the data in this report for ongoing selfassessment, and your AAAHC survey report includes comments to explain any PC or NC ratings received by your organization. Both should help to individualize the results of this overview report and to benchmark your survey results. If you have an opportunity for quality improvement, the following resources may be beneficial for interventions. Addressing High-deficiency Themes Safe Injection Practices Study Patient Safety Toolkit: Safe Injection Practices (SIP) 2. DEVELOP A TRAINING PLAN TO ADDRESS SIP DEFICIENCIES SINGLE-DOSE/MULTI-DOSE VIALS AND PRE-FILLED SYRINGES type of vial by simply looking at its size. Single-dose vials and multi-dose vials come in both large and small vials. b Is today s date BEFORE the expiration date on the label and/ or the Beyond-use-Date? c bacteria that may affect patients. e If the single-dose or single-use vial will be entered more than once for a single patient as a part of a future use. f Although MDVs typically contain an antimicrobial preservative to prevent bacterial growth, these The AAAHC Institute began offering a Safe Injection Practices Benchmarking Study in 2017. Initial findings substantiate the need for many organizations to: assess their compliance with national guidelines on safe injection practices develop quality improvement interventions to improve their compliance Based on study results, many organizations can become better informed on safe injection practices. Opportunities that AAAHC offers regarding safe injection practices include: The AAAHC Institute has been involved with the Centers for Disease Control and Prevention's (CDC s) Safe Injection Practices Coalition and has disseminated CDC-produced CDs on the subject at conferences. The AAAHC Institute developed a patient safety toolkit on safe injection practices. The AAAHC Institute offers the opportunity for organizations to benchmark their performance on safe injection practices in a study on the subject. The AAAHC Institute anticipates offering opportunities for explicit information on safe injection practices through webinars and ask the expert opportunities at upcoming Achieving Accreditation programs. The AAAHC Institute plans a series of communications through Connection e-newsletter, Triangle Times, and its surveyor newsletter on the importance and components of safe injection practices. for one injection or one procedure. d container (e.g., sharps container). e MDVs should be dedicated to just one patient whenever possible. 10, f beyond-use-date must NEVER be after the manufacturer-specified expiration date. 22 not obstruct the gradation lines on the syringe barrel and cannot easily fall off. 23, g Patient Safety Toolkit: Safe Injection Practices AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois 60077 Phone: 847.853.6060 Fax: 847.853.6118 www.aaahc.org/institute v.9.2017 11

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. The following resources can help your organization comply with AAAHC Standards. Order at www.aaahc.org. Toolkits The AAAHC Institute continues to research and release best-practice tools for patient safety. The toolkits that address themes in this report include: Allergy Documentation Credentialing & Privileging Emergency Drills Peer Review & Benchmarking Safe Injection Practices Each toolkit incorporates a review of the relevant literature, a description of the topic's importance to ambulatory health care settings, and a relevant and highly visual tool. Toolkits focus on ambulatory surgery settings, primary care settings, or are designed for universal applicability. Quality Improvement Resources Illuminating Quality Improvement is a basic resource for using data to drive meaningful improvement. This workbook includes tools and worksheets for developing a QI program, collecting and analyzing quality data, using benchmarks to establish goals, and documenting improvement in alignment with AAAHC Standards. The version available for purchase includes a 12-page Self Study Guide to walk users though each element of the resource. Selected References 1. Lamk Al-Lamki. Peer Review of Physician s Performance. Sultan Qaboos Univ Med J. 2009 (2) 109-112. 2. http://www.aaahc.org/global/pdfs/connection/2014%20november%20connecton_ The%20Peer%20Review%20Issue.pdf 3. The Guide to Clinical Preventive Services, 2014. Recommendations of the U.S. Preventative Services Task Force. Agency for Healthcare Research and Quality. March 2014. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section1.html 4. Module 7. Measuring and Benchmarking Clinical Performance. Agency for Healthcare Research and Quality, Rockville, MD, May 2013. http://www.ahrq.gov/professionals/ prevention-chronic-care/improve/system/pfhandbook/mod7.html 5. Benson HR. An introduction to benchmarking in healthcare. Radiol Manage. 1994 Fall;16(4):3509. 6. Quality Improvement Insights: Key Quality Improvement Issues and Examples for Ambulatory Health Care, 2012. AAAHC Institute for Quality Improvement. 7. Quality Improvement and Benchmarking: A Workbook of Strategies and Tools for Success, 2012. AAAHC Institute for Quality Improvement. 8. Kiefe CI, Allison JJ, Williams OD, et al. Improving Quality Improvement Using Achievable Benchmarks for Physician Feedback: A Randomized Controlled Trial FREE. JAMA. 2001; 285(22):2871-2879. 9. Allison JJ, Wall TC, Spettell CM, et al. The art and science of chart review. Jt Comm J Qual Improv. 2000 Mar;26(3):115-36. 10. Gillespie BM, Chaboyer W, Kang E, et al. Postsurgery wound assessment and management practices: a chart audit. J Clin Nurs. 2014 Nov;23(21-22):3250-61. 11. Lalloo D, Ghafur I, Macdonald EB. Peer review audit of occupational health reports-process and outcomes. Occup Med (Lond). 2012 Jan;62(1):54-6. 12. Chart Audits. Toolkit for Improving Your Office Testing Process. Agency for Healthcare Research and Quality, Rockville, MD, Aug 2013. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/office-testing-toolkit/ 13. Module 8. Collecting Performance Data with Chart Audits. Agency for Healthcare Research and Quality, Rockville, MD, May 2013. 14. Gregory BH, Van Horn C, Kaprielian V. Eight Steps to a Chart Audit for Quality. Fam Pract Manag. 2008 Jul-Aug;15(7):A3-A8. http://www.aafp.org/fpm/2008/0700/pa3.html 15. Planning a Chart Audit. Patient Safety-Quality Improvement. Department of Community and Family Medicine, Duke University Medical Center. 2014. http://patientsafetyed.duhs. duke.edu/module_b/planning.html 16. Quality Peer Review. Connection Newsletter. November 2014. Accreditation Association for Ambulatory Health Care, Inc. http://www.aaahc.org/global/pdfs/connection/2014%20 November%20Connecton_The%20Peer%20Review%20Issue.pdf 17. Mohan N., Abuzgaya F., Peczeniuk S, et al. Walking the Tightrope: Creation of the Physician Scorecard at the Rouge Valley Health System. Healthcare Quarterly, 8(3) May 2005:83-88. 18. http://www.cdc.gov/asthma/asthma_stats/uncontrolled_asthma.htm The Quality Improvement and Benchmarking Workbook includes basic material (Level I) and was used in AAAHC educational sessions. This Workbook also includes more advanced information (Level II). The information is presented in a step-by-step format, including the AAAHC "10 elements," and examples that can be used to develop a new QI program or improve an existing one. Abstracts from recent AAAHC Institute Innovations Award winning studies are included at the end of this publication. Innovations in Quality Improvement Compendium is a publication that features AAAHC Institute Kershner Award winning QI studies from 2004 to some of the more recent ones. 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 complementary and is available at http://www.aaahc.org/institute_resources. AAAHC Institute benchmarking studies are open to all ambulatory health care facilities. Participation helps organizations evaluate clinical performance measurement and build quality improvement programs. AAAHC Institute offers two opportunities, annually, to register for studies: January-June and July-December. Learn more at http://www.aaahc.org/en/institute/benchmarking/ Patient Safety Toolkit: Allergy Documentation 19. Colice GL, Ostrom NK, Geller DE, Anolik R, Blaiss M, Marcus P, Schwartz J, Nathan RA. The CHOICE survey: high rates of persistent and uncontrolled asthma in the United States. Ann Allergy Asthma Immunol. 2012 Mar;108(3):157-62. doi: 10.1016/j. anai.2011.12.017. Epub 2012 Jan 31. 20. http://www.ascquality.org/qualityreport.cfm#unplanned 21. Sargeant J, Bruce D, Campbell CM. (2013) Practicing Physicians Needs for Assessment and Feedback as Part of Professional Development. J. Contin. Educ. Prof. 33:S54-S62. doi: 10.1002/chp.21202. AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois 60077 Phone: 847.853.6060 Fax: 847.853.6118 www.aaahc.org/institute 22. Ferrante JM, Balasubramanian BA, Hudson SV et al. Principles of the Patient-Centered Medical Home and Preventive Services Delivery. Ann Fam Med. 2010 Mar; 8(2):108-116. 23. Moushey E, Shomo A, Elder N et al. Community partnered projects: residents engaging with community health centers to improve care. Fam Med. 2014 Oct;46(9):718-23. 24. Kirchhoff AC, Drum ML, Zhang JX et al. Hypertension and hyperlipidemia management in patients treated at community health centers. J Clin Outcomes Manag. 2008;15(3): 125-131. This toolkit was designed to raise awareness of the research and issues of peer review and internal benchmarking in the ambulatory surgery and primary care settings. It provides a step-by-step guide for conducting peer review and internal benchmarking including sample data collection forms. Most organization have their own policies and procedures for conducting peer review and internal benchmarking and this tool should not be used without ensuring compliance with established internal policies and procedures. Please be aware that there are inherent limitations to providing information in this format. Additional copies for personal/internal use may be ordered in electronic or printed format www.aaahc.org/institute. Copyright 2015 AAAHC Institute for Quality Improvement (AAAHC Institute). ALL RIGHTS RESERVED. Patient Safety Toolkit: Peer Review and Benchmarking AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois 60077 Phone: 847.853.6060 Fax: 847.853.6118 www.aaahc.org/institute Q Patient Safety Toolkit: Credentialing and Privileging AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois 60077 Phone: 847.853.6060 Fax: 847.853.6118 www.aaahc.org/institute Q Importance Patient Safety Toolkit: Safe Injection Practices Peer review is the evaluation of a colleague s professional performance. 1 Within the health care setting, peer review entails ongoing monitoring/measuring of important aspects of the care provided by an organization s health care professionals. 2 Conducting ongoing peer review can be used to determine: n An organization-wide performance problem (e.g., a chart audit finds that all providers do not meet United States Preventive Services Task Force [USPSTF] guidelines regarding screening for depression in adults 3 ). This is external benchmarking against a guideline and may indicate the need for an overall intervention. 4 n Variation in performance among providers (e.g., a chart audit finds large variation in average discharge time among surgeons at your organization). This internal benchmarking, comparing providers to one another, could indicate the need for a provider-specific intervention. 5,6 n Variation in performance over time (e.g., a decrease in use of appropriately timed antibiotic administration or in provision of vaccinations is noted from one chart review to the next). This is also internal benchmarking and would indicate the need for further examination that could lead to an intervention. Peer Review and Organizational Improvement It is not enough to monitor or measure performance of health care professionals. In order to improve the clinical, administrative, or financial aspects of organizational performance, benchmarking and peer review should link. Comparing results over time, among peers (internal and external to the organization) or to the organization s aggregate performance helps determine where improvements can be made. Peer review has several benefits: 7,8 n Improving patient health, safety, satisfaction, and retention n Creating efficiencies of care without compromising effectiveness n Meeting accreditation, regulatory, and/or payor requirements n Gaining a competitive edge in contracting and marketing efforts n Avoiding liability/liability insurance n Increasing skill, experience, and expertise n Using lessons learned in multiple applications n Creating/enhancing the organization s culture of quality AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois 60077 Phone: 847.853.6060 Fax: 847.853.6118 www.aaahc.org/institute v.9.2017 Q Patient Safety Toolkit: Emergency Drills AAAHC Institute for Quality Improvement 5250 Old Orchard Road, Suite 250, Skokie, Illinois 60077 Phone: 847.853.6060 Fax: 847.853.6118 www.aaahc.org/institute 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 5250 Old Orchard Road, Suite 200 Skokie, Illinois 60077 Copyright 2017 AAAHC. ALL RIGHTS RESERVED.