AAAHC Quality Roadmap Report Notes Deficiencies in Credentialing, Privileging and Peer Reviews, 100 Percent Compliance in Several Communication Standards – 12/5/2016

Credentialing and privileging of providers, and peer review as a component of privileging decisions, are among key areas for improvement at ambulatory health care facilities, according to a study just released from the AAAHC Institute.

Conversely, facilities show strong overall compliance with AAAHC Standards that encompass important communications attributes such as empowering patients to participate in decision making, providing information on fees and payment policies, and achieving consistency in documentation regarding the person responsible for the patient’s care.

The AAAHC Quality Roadmap 2016 synthesizes data from 1,363 on-site accreditation surveys performed by AAAHC from June 2015 to June 2016. Organizations surveyed include ambulatory surgery centers, office-based surgery facilities and primary care settings such as student health, occupational health and others.

“The fourth annual AAAHC Quality Roadmap lays out meaningful paths and guideposts for the ambulatory health care community to follow to further improve and excel in patient care,” said Naomi Kuznets, Ph.D., vice president and senior director at the AAAHC Institute.

Proper Credentialing, Privileging, Peer Review Areas for Improvement
Three separate yet related processes had among the highest incidence (10 percent or more) of partially compliant or non-compliant surveyor ratings for meeting AAAHC Standards at the facilities surveyed:

  • Credentialing, which validates a provider’s qualifications to offer health care services
  • Privileging, the process of governing body approval for a provider to deliver specific treatment and procedures
  • Peer review, the process of confirming a provider’s competence by enlisting similarly licensed practitioners to review clinical records and other aspects of care.

“Although the vast majority of facilities do meet the Standards, those organizations with some deficiencies in any of these areas are at risk for providers performing services or procedures for which they need additional qualifications, more experience and/or performance improvement,” Kuznets said. “If not substantially compliant, there may be threats to patient safety and risk of liability.”

Quality Improvement (QI) Programs Demand Meaningful Goals
The AAAHC Standard that addresses quality improvement (QI) studies continues to appear on the list of high-frequency deficiencies across all organization types, according to the AAAHC Quality Roadmap 2016.

“Part of being a high-performing and accreditable organization is a commitment to continuous quality improvement that can be demonstrated through well-organized and effective QI studies,” Kuznets said. “The deficiencies identified are strongly associated with the lack or inadequacy of establishing meaningful, measurable performance goals.”

To help organizations, the report outlines a “SMART” goal approach that stipulates goals should be Specific, Measureable, Achievable, Relevant and Time-bound.

Documentation Requires Attention
Requirements for proper documentation are the third topic that offers greatest opportunities for improvement, according to the report. Areas that require the most attention are allergy documentation and written evaluation of emergency drills, respectively.

“Often, an organization has a process to meet a Standard, but the process does not include follow-through in the form of written documentation,” Kuznets said. “For many Standards that are applicable to all organizations, written or electronic documentation is the primary way for AAAHC surveyors to confirm a requirement is met.”

Highest of Marks in Communications, Ethics, Fiscal Controls
Five key Standards achieved ratings of full compliance from surveyors across all AAAHC accredited organizations during the survey period reflected in the 2016 report. Surveyed facilities consistently:

  • Provide patients with the opportunity to participate in decisions involving their health care
  • Provide information to patients regarding fees for services and payment policies
  • Achieve consistency in documentation regarding the person responsible for the patient’s care
  • Engage health care professionals who consistently practice in an ethical and legal manner
  • Implement fiscal controls for rates and charges.

“Increasingly, a patient-centered approach is critical in serving today’s healthcare consumers, who are becoming more savvy and knowledgeable about medical issues,” Kuznets said.

The AAAHC Quality Roadmap 2016 is available for free download at Quality Roadmap.

About the AAAHC Institute
The AAAHC Institute for Quality Improvement (AAAHC Institute) is among the few organizations to provide ambulatory care providers with the opportunities for benchmarking on a national level. AAAHC established the Institute in 1999 to provide ambulatory health care organizations opportunities to participate in quality improvement and performance measurement studies and educational publications. To date, the AAAHC Institute has conducted and published more than 100 performance measurement studies in ambulatory health care. Involvement in clinical performance measurement is a signal to patients, government agencies, professional liability insurers and third-party payers that an ambulatory health organization is committed to continually improving the care it provides to its patients.

AAAHC (Accreditation Association for Ambulatory Health Care), founded in 1979, is the leader in ambulatory health care accreditation with more than 6,000 organizations accredited nationwide. AAAHC accredits a variety of ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, college student health centers, health plans/managed care organizations, military health care clinics, large medical and dental practices, and medical homes. In 2010, AAAHC launched Acreditas Global, an international accreditation program. AAAHC serves as an advocate for the provision of high-quality health care through the development of nationally recognized standards and through its survey and accreditation programs. AAAHC accreditation is recognized as a symbol of quality by third-party payers and medical organizations, liability insurance companies, state and federal agencies and the public. For more information, visit

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