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AAAHC “The Accreditation Association”. Selecting an Accrediting Body Carolyn Kurtz, JD July 23-24, 2007. Why is Accreditation Sought?. Public Recognition Marketing Regulatory Compliance Reimbursement Consultative Guidance Quality Improvement Specialty Society Requirements - PowerPoint PPT Presentation
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IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION
AAAHC “The Accreditation Association”
Selecting an Accrediting Body
Carolyn Kurtz, JD
July 23-24, 2007
Standards
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
Standards
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.
Standards
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.
Standards
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.
Standards
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.
Standards
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
Standards
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
Standards
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
Standards
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
Standards
IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION
Continual Growth FY ‘00/‘01 – ‘05-‘06
0
500
1000
1500
2000
2500
3000
2001 2002 2003 2004 2005 2006
Surveys
Accred. Orgs
Standards
IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION
75% Growth inAccredited ASCs
0
200
400
600
800
1000
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
Standards
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
Standards
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
Standards
IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION
AAAHC Standards
Outcome statements that reflect the characteristics that AAAHC requires of an accreditable ambulatory health care organization.
Standards
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
Standards
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
Standards
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
Standards
IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION
Types of Surveys
Early Option Consultative Initial Random Discretionary Medicare Deemed Status
Standards
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
Standards
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
Standards
IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION
Accreditation Decisions
Three year One Year Six Months Deferral Denial/Revocation
Standards
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: [email protected]