IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

AAAHC “The Accreditation Association”

Selecting an Accrediting Body

Carolyn Kurtz, JD

July 23-24, 2007

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Why is Accreditation Sought?

Public Recognition Marketing Regulatory Compliance Reimbursement Consultative Guidance Quality Improvement Specialty Society Requirements Increasing Consumer Awareness Media Influence

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

About AAAHC

Private, independent, not for profit Established 1979; 28 years dedicated exclusively to

quality improvement in ambulatory care Board of Directors; 17 National Health Care

Organizations representing the many facets of the ambulatory environment

Over 3,000 currently accredited organizations More than 312 trained surveyors, most of them

physicians, from all types of health care organizations Our Board expertise, committees & task forces examine

every issue related to ambulatory accreditation…every new trend impacting on accreditation or quality of care.

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Mission Statement

AAAHC is committed to maintaining its position as the preeminent leader in developing standards to advance and promote patient safety, quality,

value and measurement of performance for ambulatory health

care through peer based accreditation processes, education

and research.

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

What is unique about AAAHC’s Services... With 28 years of experience accrediting all types of ambulatory

organizations, AAAHC is recognized throughout the country by regulators, health plans, insurance companies, and virtually all other stakeholders.

AAAHC cares about the organizations it accredits. It’s standards are high but so is its sensitivity to the needs of accredited organizations.

AAAHC surveyors are experts…they are practicing health professionals making AAAHC accreditation a true form of peer review.

AAAHC accreditation is cost-effective…efficient… and reality-based. The accreditation process focuses on care at the patient-provider level where real quality improvement can occur.

AAAHC reviews and makes revisions of our standards necessary to meet the changes in and demands of the marketplace.

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Why should a facility choose AAAHC… Because AAAHC exists to help ambulatory care

organizations succeed in raising the quality of care.

AAAHC relies on collaboration with health care organizations to raise the standard of care and achieve buy-in from our accredited community. Accredited organizations own the standards and are proud they can comply with them.

AAAHC established the Institute for Quality Improvement (IQI) to provide value-added assistance to accredited organizations in quality measurement and improvement.

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Philosophy and Approach

Focus: Quality of care at the provider/patient level

Goal:Improve and enhance the quality and effectiveness of health care in ambulatory settings

Standards:Designed to promote excellence, professionalism and patient safety

Survey Process Focus:Assure compliance with published standards through an educational and consultative approach

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Types of Organizations Surveyed

Since its founding in 1979, AAAHC has conducted surveys in nearly every type of ambulatory organization, including:

Ambulatory Surgery Centers & Clinics Single & Multi-Specialty Group Practices Endoscopy Centers Managed Care Organizations (HMO, IPA, PPO) Dental Group Practices University and College Health Services Lithotripsy Centers Community Health Centers Occupational Health Centers Immediate/Urgent Care Centers Office-Based Surgery Centers Indian Health Centers Pain Management Centers Networks of Groups of Health Care Organizations Military Health Care Facilities

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

AAAHC Board Representation

American Academy of Cosmetic Surgery American Academy of Dental Group Practice American Academy of Dermatology American Academy of Facial Plastic and Reconstructive

Surgery American Academy of Ophthalmology American Association of Oral and Maxillofacial Surgeons American College Health Association American College of Gastroenterology American College of Mohs Surgery American Academy of Obstetricians and Gynecologists

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

AAAHC Board Representation

American Gastroenterology Association American Society of Anesthesiologists American Society for Dermatologic Surgery American Society for Gastrointestinal Endoscopy Foundation for Ambulatory Surgery In America Medical Group Management Association Society for Ambulatory Anesthesia

Public Member:Chris Strayhorn, MD - National Association of Community Health Centers

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Continual Growth FY ‘00/‘01 – ‘05-‘06

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2001 2002 2003 2004 2005 2006

Surveys

Accred. Orgs

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

75% Growth inAccredited ASCs

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400

600

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1200

1400

2001 2003 2006

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Recognition & Expansion

Federal/National Level

Centers for Medicare & Medicaid Services Deemed Status for ASCs and MedicareAdvantage

(HMOs/PPOs)

U.S. Air Force

Contract to accredit 65 ambulatory clinics world-wide

U.S. Coast Guard Contract to Accredit all ambulatory clinics: Contiguous 48

states, Alaska, Hawaii, Puerto Rico

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Recognition & Expansion Continued

State Level

- Collaborative Agreement with New York Dept. of Health for ASCs

-   Granted deemed status to survey ASCs by Indiana and Texas Depts. of Health and Ohio following

initial licensure

-   Approved to review ASCs adverse drug events programs as required by Utah Department of

Health

-   Recognized in all states requiring OBS accreditation

- Granted deemed status by California to survey OBS settings to meet state requirements

The AAAHC

Accreditation Program

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Program Fundamentals

A Peer-based program beginning with the development of standards through to the accreditation decision process

Emphasis on Education and Consultation

All organizations are surveyed by the Core standards and applicable adjunct standards

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

AAAHC Standards

Outcome statements that reflect the characteristics that AAAHC requires of an accreditable ambulatory health care organization.

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

AAAHC Standards

7 Core Chapters:Rights of Patients; Governance; Administration; Quality of Care Provided; QM&I; Clinical Records; Facilities & Environment

16 Adjunct Chapters:Chapters are applied based on the services provided by the organization

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Surveyors

312 “volunteer” surveyors nationwide Professionals who are actively involved in or have extensive

experience with ambulatory health care, including:Physicians DentistsRegistered NursesAdministrators

Surveyors receive initial credentialing/training Re-trained/Re-credentialed every 2/yrs Oversight provided by Surveyor Training and Education

Committee

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Pre-Survey/Application Process

Submit Application and Supporting Documentation Examples of Documentation

Organizational historyMission statementArticles of Incorporation/BylawsStatement of Patient Rights/ResponsibilitiesCredentialing PolicyQI Program DescriptionEmergency Plan

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Types of Surveys

Early Option Consultative Initial Random Discretionary Medicare Deemed Status

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

On-Site Survey Includes…

Opening Conference Tour and Inspection of Facility Review of select clinical records, QI projects, credentialing

files, organizational polices & procedures, and other documentation to support compliance with the standards

Individual Interviews Summation Conference

Areas that meet and do not meet standards or require improvement

Consultative advice on how to improve performance Experiences and/or resources that illustrate best

practices

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Post Survey Process

Survey team submits completed Survey Report Staff reviews the report for completeness and

consistency Accreditation Committee reviews the Survey

Report and supporting documentation and makes decision regarding accreditation

Organization receives accreditation decision letter

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Accreditation Decisions

Three year One Year Six Months Deferral Denial/Revocation

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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

Commitment to Quality

The AAAHC founded the AAAHC Institute in 1999 to provide opportunities for ambulatory health care organizations to participate in and learn about clinical performance measurement and improvement.

Thirty studies have been completed to date

Studies are designed to examine processes and outcomes

at the point of care

Quarterly workshops and annual conferences offer ongoing

opportunities for education on quality improvement "how to"

and problem solving.

AAAHC Institute for Quality Improvement

IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION

AAAHC “The Accreditation Association”

Phone: 847-853-6060Web site: www.aaahc.orgE-mail: info@aaahc.org