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AAAHC standard: Address patient safety with risk management

Ambulatory Safety Monitor, March 31, 2005

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The AAAHC board of directors approved revisions to the 2005 Accreditation Handbook for Ambulatory Health Care that provide clarifications among existing standards and include changes representative of the evolving ambulatory care environment. "Chapter 5: Quality Management and Improvement" contains several of these important modifications, including subchapter three, which is about risk management.

A look at the changes

In the 2004 handbook, the standard 5.III.B.1-17 required elements of a risk management program to address important issues, which may include the 17 substandards listed. For 2005, AAAHC changed the standard's numbering as well as the language. Now listed as 5.III.C.1-12, the standard reads: "Elements of a risk management program address safety of patients and other important issues, including the following." The substandards include all the previous elements except numbers 3, 9, and 10 which were moved to "Chapter 3: Administration" as new standards, and numbers 13 and 14, which were removed from the handbook because other chapters address the concepts.

Note: Substandard 3 regarding methods of collecting unpaid accounts becomes 3.A.6.d; substandard 9, about dealing with outside inquiries, becomes 3.A.13; and substandard 10, regarding relationships with competing organizations, becomes 3.A.14. All of these new standards have the same language as previously found in Chapter 5.

The lettering of the standard changed because the AAAHC added a new A, which renamed the original A and B standards to B and C. The new standard A says, "The governing body of the organization is responsible for overseeing the program of risk management that includes the elements listed in standard 5.III.C, and as appropriate to the organization, the requirements described in subchapter 1 of chapter 2 and chapter 3."

Adding safety to the standard broadens the requirement to ensure that the organization addresses risk management in regard to the patient, says Joan Riebock, the AAAHC's senior director of program operations. "A lot of organizations look at risk management in relation to regulatory and legal issues, but it's broader than that," she says. "Risk management should focus on the safety of the patient."

What will surveyors look for?

In the 2004 standard wording, the AAAHC said you may address the substandards. The surveyor scored these elements by saying you did or did not include them in your risk management plan. This year, however, the language says you must address the issues, and surveyors will score your compliance level as they do with all other standards: substantial compliance, partial compliance, or noncompliance.

Improving your program

To comply with the standard, first read the elements and make sure you have policies and procedures in place to address each one, says Riebock. If you don't, develop and institute them. In substandard 5, for example, you must perform a periodic review of all litigation involving the organization, its staff, and healthcare professionals. Many organizations feel that if they haven't had a malpractice suit, they don't have litigation to review. However, litigation also includes business lawsuits, legal action between partnerships, building lease cases, and grievances with contractors. Develop broad policies to address all of these types of instances.

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