Posted in: Triangle Times Today

Volume 3 | Issue 9 | September 2024

Annual Attestation and Self-Assessment Provide Keys to Ongoing Compliance

An organization that successfully navigates the AAAHC Survey process continues the 1095 Strong journey by working every day to maintain a high standard of care and a safe environment for patients and employees.

To support an organization’s commitment to 1095 Strong, AAAHC requires organizations awarded accreditation or certification to complete an Annual Attestation in the first and second years of the triennial cycle. The Chief Medical Officer, designated in the organization’s Profile, must submit an electronically signed attestation via 1095 Engage no later than the organization’s annual Anniversary Date. Failure to comply with these requirements may impact an organization’s status up to and including revocation.

Completing the Annual Attestation indicates to AAAHC that the organization is maintaining its commitment to continuous compliance and ongoing improvement. By completing this step in the 1095 Strong journey, the organization is demonstrating:

  • An accurate and updated 1095 Engage Profile
  • Review of the most current effective version of AAAHC Standards available through 1095 Engage upon version release
  • Completion of comprehensive annual self-assessment of applicable Standards and implementation of Plans Of Correction, where appropriate

The 1095 Engage Annual Attestation notification is sent to the Primary Contact and Chief Medical Officer 45 days before the annual Anniversary Date. The Chief Medical Officer can log in and complete this task any time before that date. Once the Annual Attestation is completed, it is logged into the organization’s Profile with the rest of the history.

An organization can use a variety of tools to conduct a self-assessment. To facilitate this process, AAAHC provides an Excel® based self-assessment tool preloaded with the current version of Standards. This tool is available to all organizations and accessible through the 1095 Engage Help Curtain located on the right side of the screen.

Conducting a thorough self-assessment is both an educational and continuous improvement opportunity. The process encourages clients to develop, implement, and monitor a plan to address gaps in Standards compliance. Use of the AAAHC Self-Assessment Tool or any other tool is not factored into the accreditation or certification decision, nor does the organization need to submit the results to AAAHC. However, upon a renewal or intracycle survey, the Survey team may request evidence of the organization’s self-assessment to ensure that Plan of Correction elements have been implemented and ongoing compliance is occurring.

Organizations utilizing AAAHC’s Self-Assessment Tool gain peace of mind in knowing that they are using the most current version of Standards to assess continuous compliance and are always survey ready throughout the1095 Strong journey.

For additional help preparing for a survey or remaining survey ready, AAAHC offers a library of educational materials available on 1095 Learn, AAAHC’s learning management system, which provides  valuable resources and on demand modules. To promote efficient and effective use of 1095 Engage, AAAHC has developed a comprehensive eLearning curriculum available through 1095 Learn. The course provides a step-by-step journey from application completion to Plans or Plan of Correction and the Annual Attestation. By reviewing these modules, organizations gain a deeper understanding of the new terminology, workflows, requirements, system functionality, and available resources, thereby maximizing the benefits of 1095 Engage.

Kershner Finalists Provide Insights

SURGICAL/PROCEDURAL

Reducing Same-Day Cancellations of Colonoscopy Patients
Orchard Surgical Center in Salem, NH by Melanie Ouellette, RN, BSN, CIC, Quality Manager

Our study aimed to reduce the high rate of same-day cancellations for our colonoscopy procedures. We found the initial cancellation rate to be 9%, which was above the national average of 5 to 8%.

Using interventions, such as revised and clarified colonoscopy preparation instructions, enhanced patient engagement through improved digital communication (text, emails), and regular reminders and notifications about appointments, same-day cancellations decreased from 9% to 3% within several months. This result surpassed the goal of 5%. Continuous monitoring and quarterly evaluations ensured sustained improvement.

Operating Room Terminal Cleaning Effectiveness Study
Complete Surgery Mesquite in Mesquite, TX by Corey Hollmann, RN, MSN, MBA-HCA, CNOR

Through a fluid process of regular observances and staff comments, I developed a study to see just how effective our contracted housekeeping service was at terminally cleaning our ORs and procedure rooms. Using a chemical called ‘Glow Germ,’ and a blacklight, I brought forensics to the surgery world and was able to detect ineffectively cleaned surfaces. By simply applying this chemical in random spots across our operating rooms and procedure room spaces, I determined the efficacy of our housekeeping service and identified the gaps in service that may put our patients and staff at risk. The study and follow up improved OR terminal cleaning effectiveness from 20% to 92%.

Total Joint Postoperative Length of Stay
Elliot 1-Day Surgery Center in Manchester, NH by Kelley Greulich, MSN, RN

Our recent quality improvement study aimed to reduce postoperative length of stay for our patients undergoing total joint replacement surgery. This initiative was sparked by concerns regarding patient and staff dissatisfaction with the existing discharge process.

A key component of our strategy was the training provided by our physical therapy team to our nursing staff. Nurses were equipped with the skills to assess patients’ mobility early in the postoperative period and deliver comprehensive discharge teaching. This proactive approach ensured that patients were better prepared for a safe and timely discharge, reducing the need for extended stays. Through this integrated effort, we decreased THR/TKR patients LOS from >5 hours to 3.25 hours, surpassing our goal and optimizing patient outcomes and enhancing patient satisfaction.

Primary Care

Improving Depression Screening Rates for Students
New York University Health Center in New York, NY by Jun Mitsumoto, MD, MPH, Assistant Vice President, Medical Services & Medical Director

This project aimed to improve the depression screening completion rates for students attending primary and specialty appointments from 71% to 95% by April 2024. Our intervention was to automate the depression screening process by administering the PHQ-2 via iPad during appointment check-in. If the PHQ-2 screening was positive, the student would be prompted to complete the PHQ-9. The screening data is automatically uploaded into the patient’s chart. During the patient exam, providers review and discuss the screening results, if needed, and their conversation can focus on support or treatment options.

This process change resulted in 98% of students being screened for depression during their primary care and specialty appointments. We exceeded our goal and have a sustainable, standardized process that optimizes provider time with students during the exam.

Increasing Rate of Chlamydia Screening Among Women
Sutter Bay Medical Foundation —Palo Alto Medical Foundation in Emeryville, CA by David M. Boyd, PhD

This project aimed to increase the percentage of female patients age 16 to 24 who are screened annually for chlamydia according to USPSTF recommendations from 50.2% at year-end 2022 to 60.2% by year-end 2023. PAMF historically had lower performance on this metric, compared to its performance on other clinical quality metrics.

The intervention included establishing a workflow within urgent care, primary care, and OB/Gyn clinics to collect a urine sample from women, who were due for chlamydia screening based on their health maintenance topics, during a clinic visit. Collecting and submitting the sample for testing during a visit would eliminate the need for the patient to make an additional appointment to the lab.

During the period January to June 2023, 23.1% of women with a visit had a urine sample collected. By March of 2024, the percentage had increased to 37.8%. If this level of compliance is maintained throughout 2024, the number of additional women screened through the clinic-based workflow will contribute to an increase in PAMF’s overall chlamydia screening rate above 60.2%, achieving 90th percentile level of performance.

Accelerated Hepatitis C Screening of Patient Population
Tanana Chiefs Conference in Fairbanks, AK by Stephen Gerrish, MD

Our Alaska Native population has a very high prevalence of hepatitis C, which, if untreated, can lead to liver disease, liver failure, and cancer, necessitating prolonged care and significant expenses. However, hepatitis C can be easily tested for, and when found, effective, well tolerated, and affordable treatment is available through our providers. TCC initiated a program of expanded testing, with a goal of identifying and treating all cases possible. While the CDC recommends single lifetime testing, we recognize the ongoing risk of new infections and have implemented repeat testing at a minimum of 10-year intervals. As of 2024, we have screened roughly 80% of our population, with treatment initiated in many newly identified cases.

The study accelerated hepatitis C screening of patients age 20+ by 5% annually. Our baseline of 15% screening in 2019, improved to 78% in 2024, exceeded our goal by 63% over the last 5 years. Our new goal is to achieve 95% screening of our native population.

 

Conferences & Exhibits

  • North Central College Health Association (NCCHA)
    October 23–25, Maple Grove, MN
  • Becker’s Healthcare
    October 30–November 2, Chicago, IL
  • Ohio Association of Ambulatory Surgery Centers (OAASC)
    November 13–14, Columbus, OH
  • Institute for Healthcare Improvement (IHI)
    IHI Forum 2024 December 8–11, Orlando, FL

1095 Learn

2024 Achieving Accreditation Onsite
December 12–13, Las Vegas, NV
To learn more, visit/AAnews

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