For AAAHC, quality improvement (QI) refers to the use of a reliable, repeated process to initiate and sustain improved performance over time. Sometimes organizations approach Standards related to QI with trepidation. The AAAHC Institute for Quality Improvement works to make the Standards easier to understand and implement through tools and resources.One of these tools is the “10 Elements of QI,” which forms the basis of a number of Standards found in Chapter 5 of the
Accreditation Handbook taken as a whole, the activities described by the 10 Elements become the steps in a QI study.
Element 1: The purpose
Action to take: Think about a potential problem. Describe it, why you think it is an issue, and why it matters to your
organization. Is it because:
•Itthreatenspatientsafety?
•You’vehadpatientcomplaintsaboutit?
•Itcostsyou,yourpatients,and/oryourpayers?
•Otherpeople(insideoroutsideyourorganization)seemtobedoingitdifferently?
•Someotherreason?
(continued on page 3)
Bringing quality improvement to life
UpdateFall 2012
Improving Health Care Quality through Accreditation
A publication of the Accreditation Association for Ambulatory Health Care, Inc.
Improving Health Care Quality through Accreditation 2
Like most of the Board leaders
before me, my first exposure
to the AAAHC came from
standing on the organization
side of a survey. For 30 years
I worked at the University of
Washington, the last 18 as an
administrator for Hall Health
Primary Care Center. This was
a large medical group practice
with 17 physicians and 7 nurse practitioners seeing about
500 patients a day. It was during our second AAAHC
survey that Dr. Maggi Bridwell—such a force for the
positive impact of accreditation on quality—suggested
that I become a surveyor.
That’sthebeginningofmylonghistorywithAAAHC.
After training and gaining experience as a surveyor,
I was asked to join the Accreditation Committee. This is
the group that reviews the findings of the surveyors and
makes the ultimate decision about accreditation for each
organization. I thought it would be a great educational
experience and make me a better surveyor and report
writer. Several years later I was asked to chair the
committee which I did for many years.
I joined the AAAHC board in 2004 as one of two
representatives of Medical Group Management Association
(now MGMA-ACMPE) of which I have been a member
since 1972. About 4 years ago, I was nominated and
elected to the position of AAAHC secretary. The following
year I was elected treasurer, then vice president and I
became chair of the board in April 2011. I am proud to be
the second woman, after Dr. Bridwell, to hold this position.
I have several specific goals for the board during my tenure.
I’veappointedacommitteetostudytheefficiencyand
effectiveness of the entire survey process. Just as we
require measurable quality improvement of our accredited
organizations, we demand it of ourselves as well.
It is a big task and the committee is working hard at this.
A second goal is to complete a succession plan for
AAAHC. This is a much needed way of ensuring that
we have the right infrastructure to support growth and
change. We need to retain leadership agility in an evolving
health care environment. The charge for this committee
was initiated by my predecessor, Jack Egnatinsky, MD.
Our current vice-chair, Peg Spear, MD, is overseeing the
completion of the work which is scheduled to come before
the board for approval in November.
My personal goals include balancing the opportunity
to represent the business interests of AAAHC with my
work as a surveyor. Now, I am answering questions and
addressing the concerns of our many constituents while
continuing to survey ASCs, GI centers, college and Indian
health centers. I absolutely enjoy this work. s
Karen McKellar
AAAHC Board Chair
A message from the Board Chair
AAAHC Board Chair, Karen McKellar, lives on Lake Chelan in Washington in a cabin accessible only by boat or float plane. Despite a decidedly rural base, she surveys 8 to 12 organizations seeking accreditation each year.
Element 2: The goal
Action to take:Yourperformancegoalshouldbe
appropriate and realistic. A benchmark may be available
in the literature or through a study in which you are
participating. State that you want your organization to
meet the benchmark and what it is.
Ifyoucanfindnobenchmarkandyourorganization’s
performanceisn’twithin10%ofperfect,setapercentage
goal to improve within a specified time. The farther your
organization’sperformanceisfromperfect,thehigher
a percent you choose to improve performance and the
longer the period of time you will need to do this.
Element 3: Description of data
Action to take: Look forward to describe the plan—what you
will do to get the information (data) you need to determine if
you have an issue. Include:
•Whatyouaremeasuring.
•Whereyou’regettingthedata.
•Whatyou’reusingtocollectdata.
•Whoyou’retargetingwithyourdatacollection:patients
(gender, age, medical condition, procedure), providers
(with certain types of patients or procedures), schedulers,
billing personnel, etc.
•Whowillcollectthedataandforhowlong.
•Whateverelseisnecessaryforsomeonetounderstand
how you did this.
Element 4: Evidence of data collection
Action to take: Look back to describe what happened.
Include:
•Thespecificperiodoverwhichyouactuallycollecteddata.
•Thenumberofvisits,procedures,patients,orcharts
from which you collected data.
•Theactualdatayoucollected.
Element 5: Data Analysis
Action to take:
Describe your analysis
and summarize your actual data using averages, ranges, or
percentages.
•Helpothersunderstandyourdatathroughtables
or charts.
•Includeinformationabout:
– Frequency: How often the issue occurs in your study
period—this will probably be a percentage of charts,
surveys, interviews, etc.
– Severity: A patient safety issue may not occur very often
(see Frequency above), but the implications could be so
severe (potential loss of life or disability, lawsuits, etc.)
that you would report the severity or potential severity.
– Sources: Potential reasons for your issues (e.g., patient
wait times vary with your arrival time instructions to
patients,orinformationfromabenchmarkingstudy’s
bestperformersaboutprocesses/proceduresthatdiffer
from yours.)
Element 6: Comparison of actual to goal
Action to take: Report your performance goal, your
current performance, and whether or not you met the goal.
If your current performance meets the goal, stop here and
choose a new potential problem. You have not a completed
quality improvement study because you have not improved
quality--you have only measured it.
Element 7: Corrective actions
Actiontotake:Ifyouhaven’tmetyourperformancegoal,
usewhatyou’velearnedthroughdatacollectiontobegin
corrective actions. These might include:
•Adoptingbenchmarkbestperformers’processes/
procedures.
3Fall 2012
Bringing quality improvement to life (continued from first page)
(continued on page 4)
Improving Health Care Quality through Accreditation
•Datashowingthatwhenoneissue(e.g.,arrival
instructions or anesthesia type) varies or changes, the
issue you are studying (patient wait times or discharge
times, respectively) varies.
•Issuesyouhaven’tmeasured,butthatarelikelytohave
an influence on the data (e.g., provider late arrival and
patient wait times).
Then describe:
•Thetargetoftheintervention(patient,doctor,scheduler,etc).
•Whatitis(usingchartand/orpatientreminders,posters,
education sessions, etc).
•Howlongyouwillgivetheinterventiontowork.
Element 8: Re-measurement
Action to take: Use the data collection process you
described in Element 4. Use the new data to perform the
analyses you described in Element 5. Repeat Element 6.
Ifyoustillhaven’tmetyourgoal,gotoElement9.
If you have met the goal, go to Element 10.
Element 9: Additional corrective action
Action to take: Try additional interventions using the
same process described in Element 7. Repeat the steps
in Element 8.
Element 10: Communication of results
Action to take: Describe how the results of your study were
reported to the Governing Body and refer to meeting minutes.
Describe how the results were presented to others and
refer to the documentation (personnel files, in-service sign
in sheets, meeting agendas and minutes).
Organizations seeking accreditation are not required to
use the 10 Element format for their study reports, but the
format does make it easy for both the organization and the
surveyor to rapidly review and ensure that each element is
included.
In other words, the 10 Elements can make your job and the
surveyor’sjobeasier.
Benchmarking can also make your job easier—contact us
for more information. s
Bringing quality improvement to life, continued from page 3
Quality
4
Quality Improvement and Benchmarking: A Workbook of Strategies and tools for Success covers the 10 Elements in greater detail and at a beginner and advanced level.
Innovations in Quality Improvement Compendium is a collection of award-winning QI projects.
Quality Improvement Insights is a compilation of white papers focused on specific QI topics.
5Fall 2012
At Lincoln Surgical Hospital, in
Lincoln, NE, Jan Kleinhesselink
describes her work as “educating
our staff on what quality looks like
in action.” Her role requires that she
stay current on “all things regulatory”
andit’sherenthusiasmforthecycle
of continuous learning and teaching
that distinguishes her as a surveyor for AAAHC.
“I was an OR nurse in an ambulatory surgery center
that evolved into a surgical hospital and management
group,” Jan explained. “I was asked to help our managed
ASCs prepare for accreditation. That led to a lot of staff
education and mock surveys. Our centers were accredited
byAAAHCbutI’dalsobeenthroughsurveyswithanother
accreditor, so I was familiar with several different
approaches to the process.”
On AAAHC surveys, she found a fact-finding, success-
oriented approach that strongly correlated with her own
interest in quality improvement. On one of those occasions,
AAAHC surveyor Karen Connolly asked if Jan had ever
considered becoming a surveyor herself. She had, in fact,
butatatimewhenAAAHCwasn’tacceptingapplications.
When Karen approached her, the application process was
open, so Jan applied, was invited to training, and partici-
pated in her first mentored survey in the spring of 2009.
Since then, she has been credentialed to conduct
Medicare deemed status surveys, served as an instructor
at QI-focused programs, acted as a facilitator of break-out
groups at Achieving Accreditation, and joined the board
of the Institute for Quality Improvement.
As a surveyor, Jan keeps in mind the range of her
own experiences with different accreditors and strives
to be as transparent as possible with each organization
she surveys.
“My goal is to leave them with full information. If they
can’tprovidemewithawrittenpolicy,I’llaskthemto
describe their process. The more I understand about how
they do things, the more likely it is that I can share a useful
resource.IofferasmuchastimeallowswhileI’monsite
and I write a lot on my survey reports.”
Jan continues to be most interested in education on
quality improvement.
“I think that sometimes people struggle with the premise
of QI. They often approach it as strictly regulatory –
somethingtheyhavetodo.Butit’snotaboutcollecting
data,it’saboutimprovingresults.”
“That being said, process change can be extraordinarily
challengingifyoudon’thavebuy-inandcommitment.
Thosecomefromhavingasenseofwhyyou’remaking
the change – to do it better. Understanding that was really
my aha moment.”
Jan works to bring that moment of clarity to others, both
within her own organization as Chief Quality Officer, and
to the organizations she surveys for AAAHC. “Being a
surveyor has helped me grow as a professional. It has
broadened my mind to the fact that there are a lot of
ways to do things well.” s
Surveyor SpotlightJan Kleinhesselink, RN, BSHM
Improving Health Care Quality through Accreditation
(continued on page 7)
6
Meet the AAAHC StaffGeoffrey Charlton-Perrin
With his hyphenated name and
patrician British accent, one might
mistake Geoffrey Charlton-Perrin
for a very serious person. And he is
serious – about building the AAAHC
brand, about making art, and about
keeping work and life interesting.
Geoffrey’searlycareerinadvertisingincludedhandling
marketing for clients ranging from S.C. Johnson to Blue
Cross Blue Shield. He rose to lead the Chicago office of
the Della Femina McNamee agency, then detoured to the
Chicago Convention & Tourism Bureau before exploring
an interest in associations and joining AAAHC in 2008.
“I was interviewing with John Burke,” Geoffrey recalled,
“and he asked me why I was interested in coming to a
muchsmallerorganization.I’vealwaysfeltthatapplying
the principles of marketing is really the same whether
you’reinalargeorsmallofficebutthemostfunand
excitement is when you have the opportunity to do
more, to be a jack-of-all-trades.”
Building our brand
Today, he continues to be engaged in his role as Director
of Marketing & Communications. In that capacity,
Geoffrey has had a hand in everything from strategic
planning retreats to producing videos to writing copy
for advertisements and brochures. The marketing
department, under his guidance, develops messaging
and adapts it to distinct market segments through a
range of strategies including advertising, social media,
speaking engagements, and editorial coverage. The
departmentalsomanagestheproductionofeachyear’s
suite of Accreditation Handbooks, and develops and
executes materials for the AAAHC Institute for Quality
improvement and the Accreditation Association for
Hospitals and Health Systems.
Geoffrey has been deliberate about building a family look
and feel for the previously disparate materials that we use
to tell our story.
“Any good marketer wants synergy,” he explained.
“It takes multiple contacts to transform an unaffiliated
stranger into a customer. By unifying our message across
all media, we can use a variety of channels to effectively
speed that process.”
Geoffrey refines that message by meeting AAAHC
customers (and potential customers) across the country.
He often staffs the AAAHC exhibit booth at professional
conferences, giving him the opportunity to learn about
and from the variety of organizations we accredit. These
face to face interactions help reveal the kinds of information
they value. And while there is tremendous diversity in
ambulatory health care, organizations that want to accredit,
hesays,sharetwocharacteristics:They’redrivento
excellence and they embrace the validation that a
peer-reviewer provides.
His artistic process
Geoffrey is also an accomplished writer and artist and his
approach to building the AAAHC brand is much the same
Hello
Meet the AAAHC Staff, continued from page 6
Lt. Col. Kimberly Merritt named AAAHC-U.S. Air Force Fellow
AAAHC provides an annual fellowship that supports
the training of an active duty Air Force officer in the
requirements, processes and procedures of AAAHC
accreditation. Lt. Col. Kimberly Merritt has been
selected for the 2012-2013 fellowship period, joining
the AAAHC staff in August.
During her tenure as Fellow, Lt. Col. Merritt will be
working closely with Accreditation Services staff to
gain first-hand knowledge of the what and how of a
accreditation, as well as the rationale and background
used to design the Standards and survey process. This in-
formation will be used to improve understanding of AAAHC
Standards across the Air Force Medical Service (AFMS).
After her fellowship year, Lt. Col. Merritt will be equipped
to assume an internal consultant position within the
AFMS, acting as an educational resources and interpreter,
and liaison between the AFMS and the AAAHC. s
News briefs
Fall 2012Fall 2012 7
Our final educational program of the year will take place at the Bellagio in Las Vegas. In addition to an overview of the current 2012 Standards, this is an opportunity to get an in-depth look at the final Standards that will be released for 2013.
Special program for health plan administrators
A seminar focused on health plan accreditation will run concurrently with Achieving Accreditation. This program will cover the Standards that will become effective January 1, 2013 for health plans seeking accreditation. experienced surveyors will address:
•MemberRights,Responsibilities&Protection•GovernanceandAdministration•ProviderNetworkCredentialing•CaseManagement&CareCoordination•QualityImprovementandManagement
Achieving Accreditation in Las Vegas•ClinicalRecords•EnvironmentofCare&Safety•HealthEducation&WellnessPromotion•StandardsforSpecialServices:Behavioral
Health and Dental
November 30-December 1
Bellagio, Las Vegas, NV
Find more information and register online at www.aaahc.org.
as his approach to making art. He
begins with a broad concept and a
rough sketch, but refines his product
by staying open to new decisions
as the project progresses. In other
words, he is a problem solver.
“When I was about 13, I encountered
the limited democracy of an English
Brunnhilda,2002.Paintedwood.GeoffreyCharlton-Perrin’swork emulates the whimsical, naive qualities of folk art objects in a contemporary way.
high school,” he related, “with the single elective choice
of art appreciation, music appreciation, or woodworking.”
“I figured I could learn to appreciate art and music on my
own, but that woodworking would really require a teacher.
Later, as the father of young children, I started building
some furniture and toys for my sons. Just projects that
I thought would be fun and that they would like.”
And this has been his career path, as well: following
creative opportunities as they present themselves and
looking for fun. s
Association of Military Surgeons of the United StatesNovember 12-14, Phoenix, AZ
Texas ASC AssociationNovember 15-16, Dallas, TX
Update5250 Old Orchard Road, Ste. 200Skokie, Illinois 60077
Update Fall 2012
10/12/7K© The Accreditation Association for Ambulatory Health Care. Reuse is allowed with credit to “The Accreditation Association Update newsletter” or www.aaahc.org.
Fall 2012
A publication of the Accreditation Association for Ambulatory Health Care, Inc.
Please visit us at these upcoming conferences:MGMA-ACMPEOctober 21-24, San Antonio, TX
Becker’s ASC Conference October 25-26, Chicago, IL
New Jersey ASC Association October 26, New Brunswick, NJ
ACO CongressOctober 30-31, Los Angeles, CA