Industry Voices—These are the areas where ambulatory health centers are most likely to need improvement

The Accreditation Association for Ambulatory Health Care recently released its annual Quality Roadmap 2018. (Getty/Wavebreakmedia)

The Accreditation Association for Ambulatory Health Care (AAAHC) recently released its annual Quality Roadmap 2018 analyzing data from more than 900 ambulatory healthcare accreditation surveys from 2017. The report identifies areas of both high and low compliance, providing insight on how best to improve performance and quality of care.

Here are some key takeaways which focus on documentation and quality improvement.


Requirements for documentation appear throughout AAAHC accreditation standards, ensuring there is evidence that an organization’s policies and procedures are followed. For some requirements, this written documentation is the surveyor’s primary source of information to determine compliance.


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Often, an organization has a process to meet a specific requirement, but the process does not include follow-through with written documentation. For patient safety, accurate documentation is vital, as including valuable information may help identify omissions or errors or handle liability concerns. Common areas of deficiencies in the documentation were found in:

  • Medication reconciliation
  • Informed consent
  • Allergy documentation
  • Emergency drills

To strengthen documentation practices for medication reconciliation or allergy documentation, organizations should develop a consistent documentation method and adjust required fields on charts and in the EHR system to support these practices. Medication reconciliation and allergy documentation should occur at every visit/procedure. Organizations are encouraged to conduct regular staff training of documentation requirements and perform chart audits to ensure clinical records are complete.

Informed consent forms should be reviewed to guarantee anesthesia or other related issues are part of the included information to avoid liability.

Organizations also can create a template form or checklist for emergency drills that includes space for performance notes. Having a third party and/or participants evaluate emergency drills will ensure the organizations is meeting requirements and receiving feedback. Organizations need to document that the feedback is acted upon.

Quality Improvement

To remain a high-performing healthcare organization, continuous quality improvement is essential. This calls for both a well-organized quality improvement (QI) program and meaningful, effective QI studies. Organizations should regularly monitor the effectiveness of the QI program to determine if goals are being met or if adjustments should be made. Organizations should also have ongoing monitoring of key indicators to be aware of negative changes in performance.

Once an organization believes it is not meeting specific performance goals or ongoing monitoring of key indicators indicate issues, it, can design a QI study that clearly defines a measurable goal, ensures accurate data collection and analysis, implements corrective action, and re-measures to gauge success in meeting its performance goals. Deficiencies in quality improvement typically involve:

  • Infrequent evaluations of QI programs
  • Incomplete QI studies
  • Insufficient/unclear goals, corrective actions or re-measurement processes

To improve compliance with quality improvement standards and strengthen the overall impact of the program, organizations should review QI programs at least once per year.

Incomplete QI studies may be the result of believing there is a performance issue but finding, in fact, organizational performance meets goals.  Incomplete QI studies may also be due to not achieving a performance goal, even with repeated interventions, even though the issue is still relevant.

QI studies should include clear performance goals that meet the SMART Goal criteria:

  • Specific: The goal is clear and easy to understand and translates into action.
  • Measurable: The goal is objective and can be assessed by gathering quantitative data.
  • Achievable: Those responsible for the goal have the knowledge, skills and resources to deliver the result.
  • Relevant: The goal matches the purpose of the organization and is relevant to its patients and services.
  • Time-bound: The goal has a clear completion date.

Teams should not only document but also review performance monitoring data regularly to identify trends or specific incidents that may present opportunities for improvement. By engaging in internal benchmarking activities, organizations will develop a baseline from which to gauge future performance. External benchmarking provides information about how an organization is performing relative to its peers and may also offer “best practice” information, which the organization can adopt.

Be 1095 Strong

Developing the right policies and procedures to meet requirements is step one. To ensure patient safety and positively impact performance, organizations must continually monitor performance by documenting processes and reviewing outcomes. This must go beyond the preparation for an accreditation survey that happens every three years.

Organizations should adopt, measure compliance, and enforce these policies consistently, ingraining best practices into everyday activities throughout all 1,095 days between surveys. In doing so, organizations will be better able to respond to incidents and proactively adjust procedures to make improvements, which in turn will impact patient safety and quality of care.

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