Quality improvement all 1,095 days between accreditation surveys

Every three years, or 1,095 days, accredited healthcare organizations prepare for a re-accreditation survey. While it is essential to review all policies and procedures before the surveyor arrives, many aspects of the AAAHC accreditation Standards call for ongoing documentation and evaluation between surveys. One area in particular is quality improvement, which is the driving force behind patient safety and quality of care.

Quality Improvement at the Core

AAAHC accreditation surveys cover a wide array of Standards, some of which vary depending on the type of organization. But at the core of all surveys across all ambulatory health care settings is a constant focus on quality improvement.

To remain a high-performing healthcare organization, ongoing quality improvement is essential and should include a well-organized quality improvement (QI) program and effective QI studies. Ongoing quality improvement calls for regularly monitoring the effectiveness of the QI program to determine if goals are being met or if adjustments should be made to interventions and/or goals. Once an organization determines a QI study is warranted, it must design and implement corrective action and re-measure to gauge success, with thorough documentation throughout.

Tips for Ongoing Quality Improvement

The AAAHC Quality Roadmap 2018revealed that quality improvement remains an area of focus, as many organizations struggle with developing thorough, consistent and meaningful QI studies. According to surveyor findings, many organizations that fail to meet AAAHC quality improvement Standards perform infrequent evaluations of their QI programs, offer incomplete QI studies, create unmeasurable goals, and/or fail to re-measure performance.

To advance quality improvement efforts, surveyors emphasize the importance of reviewing all QI activities at least once per year and ensure the studies include SMART Goal criteria:

o Specific: The goal is clear, easy to understand and translates into action by using words like “increase” or “decrease.”
o Measurable: The goal is objective and can be assessed by gathering quantitative data, such as 25%, 20 minutes, all or none.
o Achievable: Those responsible for the goal have the knowledge, skills and resources to deliver the result.
o Relevant: The goal matches the purpose of the organization and is relevant to its patients and services; for example, it improves compliance, increases patient satisfaction or saves money.
o Time-bound: The goal has a specific completion date, such as December 1 or by the end of the third quarter.

It is also imperative for teams to document and review performance data regularly to identify trends or specific incidents that may present opportunities for improvement. By engaging in internal and external benchmarking activities, organizations will develop a baseline from which to gauge future performance. This analysis is vital for determining the efficacy of QI activities, as well as spurring innovation and ongoing quality improvement.

Adopting an Accreditation Mindset

The accreditation experience should not end when a survey is complete, only to start again in preparation for the next survey three years later. Rather, teams should adopt policies and procedures that help ingrain best practices into activities for each of the 1,095 days of the accreditation cycle, helping accreditation standards become second nature.

Organizations seeking accreditation or re-accreditation may take advantage of educational and other resources, such as webinars, benchmarking studies, toolkits and conferences to learn about and become involved in the latest updates in accreditation requirements and best practices. These resources may offer insight and tips for meeting and exceeding requirements, while providing useful guidance on how to evaluate and adjust current practices to overcome disparities.

When preparing for an accreditation survey, or at least once a year, organizations should review all of their policies and procedures, check their documentation is in order, and review best practices with staff. Adopting an “accreditation mindset” all 1,095 days in between surveys will transform practices and simplify the accreditation process.

While it is important to take time to remind teams of performance goals and best practices, a last-minute scramble to prepare for a survey may prove stressful and insufficient. By keeping AAAHC Standards a primary focus throughout an accreditation term, ongoing quality improvement initiatives will naturally integrate with daily activities, which in turn may boost patient outcomes and overall efficiency.

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