Posted in: Government Outreach

December 8, 2023

The Leapfrog Group
Katie Stewart, Director of Health Care Ratings
1775 K Street NW, Suite 400
Washington, DC 20006

RE: 2024 Proposed Changes to the Leapfrog ASC Survey

Dear Ms. Stewart,

The Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) appreciates the opportunity to submit information related to the AAAHC Accreditation Programs and Standards in relation to the proposed revisions to the 2024 Leapfrog Ambulatory Surgery Center (ASC) survey.

Overview of AAAHC

AAAHC is a private, 501(c)(3) non-profit accreditation organization. Since its inception, the AAAHC has promoted a voluntary, consultative, peer-based, and educational survey process to advance patient care. These values hold true today, as embodied in its mission statement: Improving health care quality through accreditation. With more than 6,600 accredited organizations in a wide variety of ambulatory health care settings, AAAHC is a leader in developing Standards to advance and promote patient safety, quality care, and value for ambulatory health care through its accreditation programs, education, research, and other resources.

AAAHC Standards, published annually, are developed by clinical and administrative professionals experienced in the ambulatory space. They represent the highest level of achievement in ambulatory clinical practice and health care management. The Standards are designed to be dynamic in order to reflect evolving trends in ambulatory health care.

The AAAHC accreditation process provides a holistic review of all aspects of the organization, including its governance, day-to-day functions, staff, and the physical plant. As an accreditation organization, AAAHC evaluates health care practices against Standards that require the entity pursuing accreditation to develop its own policies, processes, and procedures to address the AAAHC framework. During an accreditation term, AAAHC expects accredited organizations to participate in ongoing quality improvement and maintain the ability to demonstrate substantial compliance with AAAHC Standards throughout the three-year accreditation term.

AAAHC Response to Proposed Changes

Survey Section 1.A – Basic Info

Integrating Environmental Services

AAAHC supports Leapfrog Group in the belief that cleaning and disinfecting, air-handling, proper ventilation, and water quality are important factors in surgical quality and patient safety. AAAHC supports removing the fact-finding question on how ASCs are integrating environmental services and facilities engineering into their quality and safety structures.

Survey Section 1.B – Billing Ethics

Itemized billing statement

AAAHC supports proposed clarifications regarding provision of an itemized bill and instructions for how to apply for financial assistance.

AAAHC supports the removal of questions that are no longer necessary to reduce the burden of participation in Leapfrog Group’s ASC Survey.

Survey Section 1.C – Health Care Equity

Measure Stratification for Equity

AAAHC believes that health equity is an issue that needs to be addressed and applauds Leapfrogs goal to urge ambulatory surgery centers to address health care equity by implementing the fundamental practices and protocols captured in the question set. While the goal is admirable, it does not examine or account for other factors that influence change such as underlying structural or cultural barriers, available resources, organizational policies and procedure. Nor does it consider accessibility based on services provided, fee structure or the vast demographics within and across communities. Further, the questions do not seek to understand what drives patients to make decisions about where they receive care.

AAAHC cautions Leapfrog that publicly reporting such measures does not achieve the desired goal, rather further calls out disparity without identifying a cause and without the needed context. Without a wholistic view of organizational culture, internal policies, specialties and community demographics, Leapfrog cannot accurately and fairly evaluate organizations against this goal.

AAAHC questions if the burden of implementation of such measures outweighs the desired outcome, based on the lack of evidence-based research and inaccuracy of non-risk adjusted data. AAAHC requests that Leapfrog conduct research into how these measures can be more accurately evaluated before publicly reporting.

Survey Section 3.A – Volume of Procedures

No or Low Volume Procedures

AAAHC supports the removal of questions that are no longer necessary to reduce the burden of participation in Leapfrog Group’s ASC Survey.

Survey Section 3.B – Volume

Bariatric Surgery for Weight Loss

AAAHC supports that facility volume can play a role in quality, as it drives provider proficiency. However, we recommend that Leapfrog Group consider how the results of surgical volume measures may affect the scoring and public interpretation as it relates to new ASC facilities. AAAHC believes that limiting reporting based upon the volume standards selected has the potential to exclude rural and solo providers, omit growing practices and those with retiring physicians, discourage mentoring of new physicians, and curb overall participation. The minimum annual facility volume of 50 may not be realistic for all ASC’s based on the aforementioned factors. Those facilities that are unable to achieve set volume will be unfavorably viewed based on factors outside their control. AAAHC suggests Leapfrog review existing data to establish a reasonable median volume requirement for surgeons and a realistic facility volume requirement that accounts for ASC facilities across all geographic regions and provider types.

Survey Section 3.C – Patient Selection and Follow-Up

Patient Selection

AAAHC supports removing the surgical appropriateness questions. Appropriateness Criteria for most common surgical procedures is still in its infancy. Availability of validation tools are still lacking, but development should be incumbent on experts representing medical associations and specialty societies.

Survey Section 3.D – Informed Consent

Removal of Questions

AAAHC supports the removal of questions that are no longer necessary to reduce the burden of participation in Leapfrog Group’s ASC Survey.

Medical Interpreter

AAAHC supports updating language to reflect the patient/legal guardian has access to a qualified medical interpreter, NOT a family member or caregiver protects patient rights.

Survey Section 3.E – Surgery Checklist

Increased Audit Sample Case Requirement

It is unclear if the extended audit period from 3 months to 12 months results in an increase in the volume of overall audits required by the organization, nor does it indicate the frequency of reporting. AAAHC reiterates that increasing the audit sample size and/or frequency of reporting during this post-pandemic time period, when ASC resources and staffing are already stretched thin, is an unnecessary increase in the administrative burden faced by ASC facilities. AAAHC also cautions that sampling without a denominator of total volume is not statistically relevant.

Survey Section 4.A – Medication Safety

Medication Clarification

AAAHC supports the proposed language added for clarification.

Survey Section 4.B – NHSN Outpatient Procedure Component Module

NHSN Group

It is unclear if this is a new requirement or general information.

Survey Section 4.C – Hand Hygiene

Removal of Questions

AAAHC supports the removal of questions that are no longer necessary to reduce the burden of participation in Leapfrog Group’s ASC Survey.

Additional Commentary

As noted in the AAAHC response to Leapfrog Groups proposed 2023 ASC Survey changes, we request that future proposed changes include additional details related to the background reasons for the proposed changes. With this information, AAAHC and other respondents can offer more meaningful feedback within our commentary.

We appreciate the opportunity to share information relating to ASC safety and quality and the AAAHC Standards and accreditation process, and hope our comments are helpful. Please do not hesitate to reach out for further clarification or with questions.


Noel M. Adachi
President & CEO

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