Posted in: Triangle Times Today
Volume 4 | Issue 8 | August 2025
Revised Plan of Correction Policy Strengthens Accountability
Survey process leads to quality improvement
In support of continuous improvement, AAAHC has refined a few policies for the release of version 44 (v44) of its accreditation and certification Standards. Specifically, AAAHC has modified the Plan of Correction (POC) policy to align with the evolving expectations of accreditation and certification processes and ensure consistency across all programs.
While organizations are expected to correct all identified deficiencies, historically, only the Medicare Deemed Status Accreditation (MDS) and Advanced Orthopaedic Certification (AOC) programs required submission of the POC to AAAHC. However, with implementation of version 43 of accreditation and certification Standards, and launch of 1095 Engage, all organizations are now required to submit an acceptable POC, regardless of program.
Submission requirements vary by program
Notable consequences
During the past year, organizations participating in the onsite survey process have demonstrated full compliance with the POC requirement and effective use of 1095 Engage for required documentation submission. Effective with v44 handbook release, AAAHC is strengthening the policy to indicate that failure to submit an acceptable POC will result in denial or revocation of accreditation or certification. This change ensures consistency across all programs and underscores the critical importance of sustainable corrective action.
This policy revision highlights AAAHC’s commitment to its 1095 Strong, quality every day philosophy emphasizing continuous improvement throughout the 1095 three-year term. For more information on developing an effective Plan of Correction and using 1095 Engage for documentation submission, refer to the October 2024 Triangle Times Today article.
Annual Self-Assessment Promotes Readiness and Continuous Improvement
Conducting a comprehensive annual self-assessment ensures that your organization is survey-ready and consistently maintaining compliance with AAAHC Standards throughout the year. Prior to your first survey and annually for all organizations awarded accreditation or certification, your organization is required to attest to completion of an annual self-assessment including documentation and implementation of corrective action.
The self-assessment serves several key functions:
• Self-evaluation of compliance
Organizations use the self-assessment to evaluate how well they are adhering to current applicable AAAHC Standards. This includes evaluation of all areas: patient safety, infection control, documentation practices, credentialing, privileging and personnel practices, physical environment, and governance and leadership.
• Identification of gaps and risks
By performing a structured self-review, facilities can:
• Detect non-compliance or opportunities to strengthen compliance early—and not be rushed prior to a survey.
• Uncover potential risks to patient safety or operational efficiency.
• Prioritize corrective actions before formal surveys.
• Continuous quality improvement
An annual self-assessment supports a culture of continuous improvement by prompting organizations to:
• Analyze their processes regularly.
• Implement improvement plans.
• Monitor the impact of changes over time.
• Documentation and accountability
The annual self-assessment provides a documented record showing that the organization is:
• Monitoring its performance against Standards.
• Taking proactive steps to stay in compliance.
• Engaging leadership and staff in quality improvement and safety efforts.
• Preparation for accreditation/certification survey
The self-assessment acts as a rehearsal for the actual accreditation/certification survey by:
• Familiarizing staff with survey expectations.
• Ensuring that policies, procedures, and practices are aligned with Standards.
• Helping to reduce the risk of deficiency citations during the actual survey.
The annual self-assessment is a vital tool for maintaining survey readiness, improving patient care, and fostering organizational accountability. It transforms accreditation/certification from a one-time event into an ongoing process, aligning with the AAAHC philosophy of 1095 Strong, quality every day.
Where to start
Organizations most effective in conducting self-assessments integrate this activity into the very fabric of their quality improvement/continuous compliance QAPI plans, policies, and activities. To conduct a comprehensive self-assessment effectively, consider a structured approach.
• Understand the AAAHC Standards
• Download the most recent effective version of AAAHC Standards located in the 1095 Engage Help Curtain. Once logged into the portal, navigate to the gray Help Curtain button that appears on the right-side of the screen.
• Review the Handbook carefully (e.g., patient rights, infection control, credentialing).
• Consider registering for a AAAHC Achieving Accreditation live or virtual conference. This program is an interactive, immersive event designed to help you learn and prepare for your AAAHC survey while developing a deeper understanding of AAAHC Standards to ensure ongoing compliance. Whether your organization is new to AAAHC, you are new to your role in the renewal process, or you simply want to refresh your knowledge of Standards, this program can help.
• Access the AAAHC Self-Assessment Tool from the 1095 Engage Help Curtain. This Excel-based resource can help you assess your organization’s compliance with AAAHC Standards and foster ongoing survey readiness. Note that use of this tool is not considered by AAAHC during the survey or when rendering an accreditation or certification decision. You can use this tool to document compliance commentary and link Standards with your facility’s policies and procedures. Refer to the 1095 eLearning module for guidance on accessing this tool in 1095 Engage.
• Several Policy Management Software (PMS) vendors have integrated AAAHC Standards and offer functionality that facilitates self-assessments. If working with a PMS vendor, leverage these resources to guide your compliance assessment.
• Assign a self-assessment team
• Form a multidisciplinary team including clinical leaders, administrative staff, compliance officers, and quality improvement personnel.
• Assign specific AAAHC Standards Categories to appropriate team members. The self-assessment can be scheduled into your team’s daily workload—
it doesn’t have to be conducted in one day or a single week, but activities should be planned with results aggregated and documented.
• Collect documentation and evidence
For each Standard:
• Gather relevant policies, procedures, logs, and records. Examples include training logs, incident reports, infection control audits, HR files, and credentialing documents.
• Ensure documents are current and reflect actual practice.
• Establish a clinical record sampling methodology to maintain objectivity and relevance that reflects the workload, provider, and patient distribution for your organization.
• Leverage the Clinical Record, Personnel, and Credentialing & Privileging worksheets contained in the AAAHC Self-Assessment Tool. While these worksheets are not linked to the overall report, they are useful in understanding what to look for in your review and should contribute to your self-assessment of compliance.
• Evaluate compliance using a structured approach
• Use the AAAHC Self-Assessment Tool or an alternative structured self-assessment tool or checklist (provided by your policy management software vendor or internally developed).
• Rate each Standard including the Statement of Requirements (SOR), Elements of Compliance (EOC), and Sub-Elements of Compliance (SEOC) with the rating methodology specified in the handbook. SORs are rated from Fully Compliant (FC) to Non-Compliant (NC) depending on the roll-up of EOC and SEOC Yes/No ratings. If using the AAAHC Self-Assessment Tool, refer to your 1095 Engage curated Standards first to allow focus on those areas most relevant to your organization. Note: Accurate curation requires that your Application/Profile is up to date and correctly reflects your organization.
• Identify gaps and risks
• Note deficiencies and their potential impact.
• While all gaps need to be addressed, consider prioritizing your corrective action based on the risk the gap poses to patient safety, operational efficiency, or regulatory compliance. The AAAHC SOR Level can assist with this prioritization. Level 1 includes Standards which specify, or apply to, activities or processes which DO NOT involve the provision or conduct of patient care, OR the assurance of patient or employee safety. Level 2 Standards specify, or apply to, activities or processes which involve the provision or conduct of patient care, OR the assurance of patient or employee safety.
• Develop a Plan of Correction (POC)
For each deficiency identified include:
• POC details: Description of the actions to be taken to correct each deficiency and achieve compliance. This should include what and how actions, resources, policies, or procedures were implemented. If there are multiple findings for one Standard, address each finding.
• POC documentation: Evidence of corrections to be implemented (e.g., work orders, service contracts, draft policies).
• Correction effective date: Date that the corrective actions will be completed; set realistic timelines that also weigh the impact of the deficiency and associated urgency.
• Evidence of compliance: Evidence of how the correction was made, (e.g., approved policies, audit templates, in-service records, training or audit schedules, photographs, paid invoices).
• Responsible party: Specific person, committee, or party responsible for ensuring the POC is effective. Note: for POCs submitted to AAAHC, do not use individual’s names in your submissions.
• Monitoring activities: Ongoing, time-specific actions to be performed to ensure the corrections are effective, and that the specific deficiency cited remains corrected and/or in compliance with AAAHC Standard requirements.
Document the assessment
• Prepare a formal report summarizing:
• Overall findings.
• Key compliance strengths.
• Identified deficiencies.
• Corrective action plans including responsible parties and deadlines—and any resources required.
• Report to leadership
• Present the findings and action plans to your governing body.
• Gain approval for necessary resources or policy changes.
• Implement improvements
• Execute action plans.
• Track progress regularly.
• Update policies, train staff, and revise workflows as needed.
• Monitor and reassess
• Schedule follow-up reviews.
• Use results to refine ongoing quality
improvement efforts.
• Incorporate the self-assessment into your annual quality and risk management calendar.
Motivate the team
Motivating your team to engage in the annual self-assessment is essential for its success. Here are effective strategies to build motivation and ensure active participation:
• Connect your self-assessment to purpose and patient care
• Frame it as a quality and safety initiative, not just a compliance task.
• Remind the team: “This is how we deliver the best patient care possible.”
By participating in your organization’s self-assessment, you’re directly contributing to better patient outcomes and reducing risk for everyone.
• Assign meaningful roles
• Give staff ownership over specific Categories or Standards that relate to their job (e.g., clinical staff for infection control, administrative team for patient rights). This increases engagement and accountability.
• Consider rotating assignments each year to build broader knowledge.
• Recognize contributions publicly
• Acknowledge individuals or teams in staff meetings, newsletters, or bulletin boards.
• Offer small rewards (certificates, gift cards, extra break time) for meeting self-assessment milestones.
• Provide training and tools
• Make sure staff understand what the self-assessment is and how it works.
• Provide clear instructions, checklists, and sample documentation.
• Consider short lunch-and-learns or “Self-Assessment Kick-Off” meetings to help frame the initiative and build enthusiasm.
• Show progress and impact
• Share data on improvements or how findings led to better processes (e.g., reduced medication errors or faster patient throughput).
• Celebrate wins, no matter how small.
• Respect their time
• Integrate the self-assessment into existing workflows or QAPI projects.
• Set realistic deadlines and avoid “dumping” work suddenly. Consider breaking it up into manageable tasks with clear time frames.
• Involve leadership
• When directors and senior staff participate, it signals the self-assessment is a priority.
• Leaders should model engagement and publicly support the process.
• Ask for feedback
• After each cycle, ask, “What went well? What could we improve?”
• Implement suggestions where feasible to show that their input matters.
An organization’s annual self-assessment isn’t just about passing a survey—it’s about making sure the patient care you deliver is safe, documentation is strong, and your patients can trust you. Members of your team can bring critical insights to the table, and their role in this process helps shape the future of your organization.
It’s about ensuring your organization is 1095 Strong and delivering quality every day.
Achieving Accreditation highlights v44, presents interactive opportunities
to exchange knowledge
The September AAAHC virtual Achieving Accreditation program directly supports the AAAHC mission of improving health care quality through accreditation. By offering an immersive two-day virtual event focusing on AAAHC Standards application, interpretation, performance metrics, and best practices, the program empowers ambulatory professionals to enhance their understanding and implementation of quality patient care.
The inclusion of the v44 Standards and insights from AAAHC faculty further reinforces the organization’s commitment to continuous quality improvement and patient safety, aligning with the AAAHC philosophy of 1095 Strong, quality every day. Through interactive breakout sessions, peer-to-peer learning, and networking opportunities, the program facilitates the exchange of knowledge and challenges, ultimately fostering a stronger sense of community among ambulatory professionals and promoting the consistent delivery of high-quality patient care. This educational initiative, including access to on demand session recordings, through November 16, 2025, provides a valuable resource for organizations seeking to achieve and maintain AAAHC Accreditation and continuously elevate their standard of care.
For more details on upcoming Achieving Accreditation—including the virtual program in September— please click here.
Conferences & Exhibits
- California Ambulatory Surgery Association
September 3–5, San Diego, CA - Ohio Association of Ambulatory Surgery Centers
September 24–25, Columbus, OH - Becker’s Healthcare October 15–18, Chicago, IL
1095 Learn
- 2025 Achieving Accreditation
September 15–17 Virtual - December 11–12, Red Rock Casino Resort and Spa, Las Vegas, NV
Learn more about upcoming Achieving Accreditation programs
