Standards Compliance Analysis Shows Where Ambulatory Organizations Excel and Where They Struggle


The Accreditation Association for Ambulatory Health Care (AAAHC) revealed today a proprietary research report from its Institute for Quality Improvement (AAAHC Institute) that identifies overall trends in the burgeoning ambulatory healthcare field, while also shedding light on where ambulatory organizations excel and where they struggle.

The AAAHC Institute AENEID* report highlights ambulatory organizations high marks for respecting and involving patients in the health care decisions, as well as for cost-controlling measures such as concern for relevance for treatments and administrative efficiencies. The report also examines areas that need continued focus from ambulatory organizations, including proper documentation of patient allergies and practice privileges for healthcare professionals, as well as suitable internal emergency and disaster preparedness planning.

For 35 years, AAAHC has collected performance data on ambulatory healthcare organizations, and the AENEID initiative represents the first time were transforming our warehouse of information into a useable educational tool, both for our accredited organizations and for the industry as a whole, says John Burke, PhD, president and CEO of AAAHC. The AENEID identifies overall trends in ambulatory healthcare and allows us to see patterns of compliance with AAAHC Standards and to sort and analyze the results in multiple ways.

Founded in 1979, AAAHC is the leader in ambulatory healthcare accreditation with nearly 6,000 organizations accredited nationwide. The AAAHC Institute AENEID* report analyzes more than 700 individual data points from more than 1,500 surveys conducted from June 2012 to June 2013 under the organizations 2012 Standards. These surveys cover all major healthcare settings such as ambulatory surgery centers (ASCs), office-based surgery practices (OBS), and primary care organizations (PCOs). AENEID results show overall trends in compliance and noncompliance across the variety of ambulatory organizations, and also identify specific trends and challenges for healthcare organizations by setting.

The AENEID is more than a report card summarizing results; its a valuable tool for quality improvement, says Naomi Kuznets, senior director and general manager for AAAHC Institute. In mining its results, we gain a deeper understanding of the interpretation and implementation of Standards that allows us to better prepare ambulatory organizations to gain compliance in each and every area.

Detailed Findings
As part of its peer based accreditation process, AAAHC surveyors meet in person with organizations seeking accreditation to discuss and rate a series of Standards as substantially compliant (SC), partially compliant (PC), or non-compliant (NC).

Excellence Across the Board
Overall, AAAHC accredited organizations were highly successful (99.9% or greater scored as SC) in meeting Standards including:
 Standard 1.A: Patients are treated with respect, consideration, and dignity.
 Standard 1.E: Patients are given the opportunity to participate in decisions involving their healthcare, except when such participation is contraindicated for medical reasons.
 Standard 4.L1: Concern for the costs of care is demonstrated by the following: The relevance of healthcare services to the needs of the patients. (Edited for 2013.)
 Standard 4.B: Health care professionals practice their professions in an ethical and legal manner.
 Standard 3.A.8: Administrative policies, procedures and controls are established and implemented to ensure the orderly and efficient management of the organization. Administrative responsibilities include, but are not limited to: Controlling the purchase, maintenance, and distribution of the equipment, materials, and facilities of the organization.

Top Ambulatory Challenges
Overall, AAAHC accredited organizations were commonly cited as deficient (10-25% scored as PC or NC) in meeting Standards including the below. An analysis of surveyor comments found that, for these areas of inspection, multiple components may have driven the relatively high proportion of these ratings.

 Standard 2.II.D: Privileges to carry out specified procedures are granted by the organization to the healthcare professional to practice for a specified period of time. The health care professional must be legally and professionally qualified for the privileges granted. These privileges are granted based on an applicants qualifications within the services provided by the organization and recommendations from qualified medical personnel.
 Standard 6.K: The presence or absence of allergies and untoward reactions to drugs and materials is recorded in a prominent and consistent location in all clinical records. This is verified at each patient encounter and updated whenever new allergies or sensitivities are identified.
 Standard 8.E: 2012 wording: The organization requires at least one (1) drill each calendar quarter of the internal emergency and disaster preparedness plan.* One (1) of the annual drills must be a documented cardiopulmonary resuscitation (CPR) technique drill, as appropriate to the organization. The organization must complete a written evaluation of each drill, and promptly implement any needed corrections or modifications to the plan. *Appropriate to the facilitys activities and environment. Examples include medical emergencies, building fires, surgical fires, tornados, hurricanes, earthquakes, bomb threats, violence, and chemical, biological, or nuclear threats.

The term AENEID, an acronym for Accreditation Association Electronic National Evaluation and Information Dataset, harkens back to the famous Roman founding myth of the same name penned by Virgil and emphasizes the importance of the data as a foundation for future education and improvement.

The 2013 AENEID report was the first step in our ongoing effort to offer proactive, meaningful solutions that will help organizations on the path to accreditation, says Burke. Were developing additional guidance to support improvement of these standards in 2014.

The complete findings, along with AAAHC Institute proactive improvement efforts, can be downloaded from the AAAHC website at

*Accreditation Association Electronic National Evaluation and Information Dataset

Source: AAAHC Institute for Quality Improvement and the  Accreditation Association for Ambulatory Health Care

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