Most Common Deficiencies For AAAHC Chapter 5-I “Quality Improvement Program”

The most common deficiencies our surveyors see for Chapter 5-I “Quality Improvement Program” of the AAAHC Accreditation Handbook for Ambulatory Health Care:

  • The QI Program must be in writing – Even though all organizations tend to have their QI Program in writing, it must include specific objectives it aims to achieve. This is where many centers are deficient.

  • The QI Program is evaluated annually for effectiveness and to determine if the program purposes and objectives continue to be met. Be sure to continue to review your program to meet this requirement.

  • The result of that evaluation is reported to the governing board and throughout the organization – This is the most common deficiency we see. Organizations tend to have a written QI program but are missing measurable objectives. Also, few have a program evaluation. If you do not have an evaluation, then it does not get reported to the board, which is also a deficiency. If the program is evaluated, the Governing Board meeting minutes should reflect that.

  • All QI activity and studies are reported to the governing board. Often, there is no mention in the board minutes of any QI studies or external benchmarking.

  • The center must conduct both internal and external benchmarking. Most centers conduct internal benchmarking. However, many are deficient in external benchmarking. Even centers that do cite the organization(s) against which they conduct their external benchmarking, they often fail to provide any evidence of this activity nor report it in the board minutes.

  • QI studies must contain the 10 steps (elements). Surveyors always review a minimum of two complete QI studies. Sometimes, centers present studies showing they achieved their study goal, therefore, no corrective action was required. Such studies do not count if no problem was found and no corrective action was required.

To learn how HealthCon can assist with your accreditation/certification needs, visit www.healthconcorp.com or contact us at kmighion@healthconcorp.com

*Sources:

  1. “AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.

  2. HealthCon Consultant survey experience

Kristine Mighion, MD, MBA