The Accreditation Association for Ambulatory Health Care recently released a first-of-its-kind report, Accreditation Electronic National Evaluation and Information Data Set (AENEID), detailing 2012-2013 data on accreditation compliance trends in ambulatory organizations. The report is comprised of survey data, which was recently converted to an electronic data warehouse containing AAAHC accreditation compliance data from 2007 up through 2013.
AAAHC plans to use the accumulated information in a new set of quality improvement efforts to help accredited or accreditation-seeking organizations understand where they might fall short and how they can do better. Naomi Kuznets, PhD, senior director and general manager for the AAAHC Institute for Quality Improvement, sheds some light on the triumphs and tribulations of ambulatory organizations seeking accreditation.
Question: What do ambulatory facilities do well in the accreditation process?
Naomi Kuznets: There are a number of areas in which they do well. They operate in accordance with federal and state antidiscrimination laws. They effectively address administrative responsibilities related to purchase, maintenance and distribution of equipment, effectively outfitting themselves and maintaining their capital, which is especially important when you have equipment touching people's bodies and affecting people's health. Ambulatory facilities also practice ethically and legally and provide services relevant to needs of their patients. They're great at maintaining their clinical records in a way that includes basic patient information, which is invaluable for patient identification and prevention of wrong-site surgery.
Q: Where do ambulatory facilities struggle in the accreditation process?
NK: The standards most at issue have to do with quality standards — quality improvement — quality improvement activities, setting goals for quality improvement activities, measuring whether an intervention has made any difference compared to the goal. We've known for years quality improvement efforts are difficult for organizations, and we've been addressing those issues. We will continue to emphasize issues with goal-setting and measuring performance against goals.
Others issues are with regards to privileging. Organizations don't think of all the folks in [the] organization providing patient care whose credentials and experience need to be reviewed in order to make sure what they do is appropriate to their credentials and experience. This information also needs to be recorded and updated at prescribed intervals.
Another issue is in the documentation of allergies. When clinicians note in a chart that a patient has an allergy, they don't always note what the manifestation of the allergy is, which is a problem, because hives are really different from anaphylaxis.
A final issue is emergency drills. People do them, but maybe they're not doing them frequently enough or in accordance with local and state requirements. They also may not be recording what they did for drills, so they can't address and improve trouble areas, such as the time it takes to execute an emergency drill or confusion about everyone’s role in the drill.
Q: Are there any surprises to those trouble areas?
NK: Aside from the issues associated with the quality improvement standards, we've known credentialing and privileging is not easy, because it requires persistence, and it's repetitive. For emergency drills organizations may not understand that documentation and improvement in emergency drills is important, it's an issue. That was an issue we didn't necessarily expect.
Q: What's AAAHC's plan to help organizations improve?
NK: Something we understand after analyzing surveyor comments is that certain aspects of requirements are more challenging than others. Realizing this, something we're doing for 2014 is we’re focusing on all aspects of allergy documentation, emergency drills and credentialing and privileging to help ambulatory facilities improve. For example, we're working on a specific AAAHC toolkit on emergency drills for our accredited organizations.
Also, we urge centers to take advantage of educational programs and materials, to read the AENEID and to look at their performance compared to trends to identify potential trouble issues. And, as always, we're very approachable and willing to help!
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AAAHC plans to use the accumulated information in a new set of quality improvement efforts to help accredited or accreditation-seeking organizations understand where they might fall short and how they can do better. Naomi Kuznets, PhD, senior director and general manager for the AAAHC Institute for Quality Improvement, sheds some light on the triumphs and tribulations of ambulatory organizations seeking accreditation.
Question: What do ambulatory facilities do well in the accreditation process?
Naomi Kuznets: There are a number of areas in which they do well. They operate in accordance with federal and state antidiscrimination laws. They effectively address administrative responsibilities related to purchase, maintenance and distribution of equipment, effectively outfitting themselves and maintaining their capital, which is especially important when you have equipment touching people's bodies and affecting people's health. Ambulatory facilities also practice ethically and legally and provide services relevant to needs of their patients. They're great at maintaining their clinical records in a way that includes basic patient information, which is invaluable for patient identification and prevention of wrong-site surgery.
Q: Where do ambulatory facilities struggle in the accreditation process?
NK: The standards most at issue have to do with quality standards — quality improvement — quality improvement activities, setting goals for quality improvement activities, measuring whether an intervention has made any difference compared to the goal. We've known for years quality improvement efforts are difficult for organizations, and we've been addressing those issues. We will continue to emphasize issues with goal-setting and measuring performance against goals.
Others issues are with regards to privileging. Organizations don't think of all the folks in [the] organization providing patient care whose credentials and experience need to be reviewed in order to make sure what they do is appropriate to their credentials and experience. This information also needs to be recorded and updated at prescribed intervals.
Another issue is in the documentation of allergies. When clinicians note in a chart that a patient has an allergy, they don't always note what the manifestation of the allergy is, which is a problem, because hives are really different from anaphylaxis.
A final issue is emergency drills. People do them, but maybe they're not doing them frequently enough or in accordance with local and state requirements. They also may not be recording what they did for drills, so they can't address and improve trouble areas, such as the time it takes to execute an emergency drill or confusion about everyone’s role in the drill.
Q: Are there any surprises to those trouble areas?
NK: Aside from the issues associated with the quality improvement standards, we've known credentialing and privileging is not easy, because it requires persistence, and it's repetitive. For emergency drills organizations may not understand that documentation and improvement in emergency drills is important, it's an issue. That was an issue we didn't necessarily expect.
Q: What's AAAHC's plan to help organizations improve?
NK: Something we understand after analyzing surveyor comments is that certain aspects of requirements are more challenging than others. Realizing this, something we're doing for 2014 is we’re focusing on all aspects of allergy documentation, emergency drills and credentialing and privileging to help ambulatory facilities improve. For example, we're working on a specific AAAHC toolkit on emergency drills for our accredited organizations.
Also, we urge centers to take advantage of educational programs and materials, to read the AENEID and to look at their performance compared to trends to identify potential trouble issues. And, as always, we're very approachable and willing to help!