Posted in: Triangle Times Today

Volume 2 | Issue 9 | September 2023

Demonstrate a high level of patient care through quality improvement

With standards dedicated to governance, risk management, patient care, and quality, AAAHC provides a framework for organizations to evaluate compliance, identify improvement opportunities, and implement quality initiatives that are underpinned by the AAAHC 1095 Strong, quality every day philosophy. Implementing this philosophy requires dedication to quality improvement, a cornerstone of accreditation.

Part of being a high-performing and accreditable organization is involvement in continuous quality improvement. A well-organized quality improvement (QI) program and effective QI studies are essential. The quality standards ensure that organizations implement a QI program that includes ongoing data collection, analysis of trends, examination of performance versus external peers (i.e., external benchmarking), and steps to correct/improve performance. According to the AAAHC Quality Roadmap, Quality Management and Improvement stands as the fifth top deficiency. Common deficiencies related to this Standard include unclear purpose and goals and no corrective action or remeasurement.

Organizations should be regularly monitoring the effectiveness of their QI program to determine the program’s purpose and goals. Using external benchmarking, organizations develop their goals, whenever possible. Approaches to the goals should be revisited—in general, to determine the  position of the organization’s QI program. Once an organization determines a QI study is warranted, the organization must design and implement corrective action and remeasure to see whether the corrective action achieved the performance goal set by the organization. Without remeasurement, the QI study is incomplete.

National Health Care Quality Week occurs on the third week of October each year. This creates a great opportunity to revisit your QI program, evaluate your compliance with AAAHC requirements, celebrate your achievements, and share your success.

  1. Host a Lunch and Learn, education session or poster presentation on the quality improvement efforts that are happening in your organization.
  2. Give recognition to the quality professionals and champions in your organization. Let them know how much you appreciate their efforts!
  3. Use social media to create awareness, highlight your work, and share your success stories.
  4. Collaborate with teams within your organization or in other organizations for best practice ideas for improvement. Don’t keep those best practices to yourself.
  5. Review your recent QI Studies. Share your improvements and celebrate!

Did your recent study showcase innovative thinking and working as a team? Could other ambulatory health care settings benefit from your findings? Have you maintained the improvements? If so, AAAHC encourages you to submit that study for a 2024 Bernard A. Kershner Innovations in Quality Improvement Award. Submissions open January 3, 2024.

Has your organization been celebrating? If you do, what are some activities? Let us know at

v42 Q&A, Part VII

This month, AAAHC continues our ongoing series of AAAHC Standards Q&A focusing on quality improvement.

What are the key characteristics of a quality improvement program?

Key characteristics of a quality improvement (QI) program are addressed in the AAAHC Standards. The QI program Standards require that the written QI program addresses the full scope of the organization’s health care delivery services and describes how these services are assessed for quality. Detail the purpose of the program and specific objectives along with a description of the ongoing data collection process. Finally, describe how the organization integrates quality improvement activities, peer review, and the risk management and infection prevention and control programs.

How often should the quality management and improvement program be reviewed?

AAAHC requires that documentation demonstrates at least annual governing body review of the QI program to evaluate effectiveness and determine if the purposes and objectives continue to be met.

How many quality improvement studies does AAAHC require?

AAAHC Standards require that the organization demonstrates that continuous improvement occurs by conducting quality improvement studies when the data collection processes indicate that improvement is or may be warranted. At least one current quality improvement study demonstrates that improvement occurred and has been sustained. “Current” is defined as within the current accreditation term, or within the last 12 months for initial surveys. In addition, AAAHC offers a resource, Developing Meaningful Quality Improvement Studies, to help organizations improve their quality and safety of care. Some programs or states may have additional requirements.

Understanding that peer review is integrated into the quality management and quality improvement program, which health care professionals can peer review each other?

Organizations may determine which health care professionals can peer review each other, within the following guidelines: Differently licensed practitioners reviewing each other must be privileged to provide similar services to similar patients; and prevailing laws must permit peer review by differently licensed practitioners.

For near miss events, what follow up documentation if any, does AAAHC require?

AAAHC Standards require all adverse events and incidents that could have resulted in an adverse event (i.e., near miss events) are analyzed to identify the basic or causal factors underlying the incident. Improvements in processes or systems to reduce the likelihood of such incidents in the future should be implemented and communicated internally and in accordance with laws and regulations.

Conferences and Exhibits

  • Becker’s ASC Business and Operations of ASCs
    Oct 26–28
  • IHI Forum — Institute for Healthcare Improvement
    Dec 10–13

1095 Learn

Achieving Accreditation

  • Onsite, Dec 7–8 (Las Vegas)

Learn more and register.

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