Safety

Be aware of extensive QI revisions to Chapter 5

Ambulatory Safety Monitor, May 19, 2005

Want to receive articles like this one in your inbox? Subscribe to Ambulatory Safety Monitor!

The AAAHC's revised Chapter 5: Quality Management and Improvement contains several changes in subchapter II regarding the quality improvement (QI) program. Elements of a QI program, QI studies, and benchmarking highlight the revised section, says Joan Riebock, the AAAHC's senior director of program operations. "We wanted to help organizations understand the characteristics of developing an effective QI program so they can build on that framework," she says.

Recognize changes to the language

In the interest of consistency, the AAAHC began using the word "activity" in this edition of the standards. Found in standard 5.II.A.6, for example, activity is synonymous with "study" in this context. Also remember that use of the term "healthcare professionals" in this chapter includes all clinical and administrative personnel.

Build a quality QI program

Other changes to the subchapter's content include nine additions to standard A, which outline the characteristics of the QI program. These additions were made because the AAAHC says organizations needed more clarity in this area. Following are the new standards:

  • A written description of the program, addressing the scope of the organization's services and how it assesses the QI plans for these services

  • Identification of individuals or committees responsible for the program

  • Healthcare providers' participation in the program, including at least one physician

  • QI goals

  • Development of a process to determine problems in meeting your goals

  • Identification of QI activities (e.g., studies, benchmarking) that support the goals of the QI program

  • Definitions of the links between QI activities, peer review, and the risk management program

  • Evaluation of the effectiveness of the program at least annually

  • Establishment of processes to report QI activity results to the organization, including the governing board

    Closing the loop

    AAAHC participants realize the importance of "closing the QI loop." The accreditor previously defined closing the loop as completing the five predetermined steps of a successful QI activity. The 2005 revisions expand section B, and it now contains seven requirements. The following are new to the list this year:

  • Identification of performance measures, goals, and objectives

  • Identification, analysis, and implementation of more corrective actions, if problems persist, to sustain improvement

    The AAAHC also expanded the list of potential study topics to help you close the loop. New areas to consider include testing new or enhanced processes or methods of care; benchmarking against best practices, professional practice guidelines, and performance measures; and short- or long-term planning goals.

    New direction for benchmarking

    "Organizations frequently tell us they have difficulty doing benchmarking because they have nothing to benchmark against," Riebock says. To help organizations overcome this common obstacle, the AAAHC modified section C of subchapter 5.II, which covers the process.

    Many small, single-specialty ambulatory surgery centers (ASC) struggle with the approach that requires them to benchmark themselves against other facilities because finding a similar organizational model is difficult. Rather than searching for an identical organization with which to compare yours, the AAAHC now allows you to benchmark against recognized best practices of national or professional targets or goals.

    For example, look for information from the Agency for Healthcare Research and Quality as a possible source, or other professional healthcare or medical organizations such as the Federated Ambulatory Surgery Association or the AAAHC's Institute for Quality Improvement. Other sources for benchmarking opportunities include published studies in peer review journals. Literature may include reports on topics such as infection rates or postsurgery nausea.

    Regardless of which type of benchmarking your organization takes on, getting started is key.



    • Want to receive articles like this one in your inbox? Subscribe to Ambulatory Safety Monitor!

      Hospital Safety Center

    • Hospital Safety Center

      Improve compliance with hospital safety standards from The Joint Commission, OSHA, and other regulators with this...

    • Healthcare Life Safety Compliance

      Learn Life Safety Code tips and interpretations for healthcare facilities with this in-depth monthly resource.

    • Hospital Safety Connection

      Stay on top of hospital safety requirements and best practices with our free, fast-paced weekly update.

    • Administering Your OSHA Program

      This course will help an employee new to the role of OSHA safety officer. It gives an overview of OSHA requirements and...

    • Medical OSHA Manual Combo

      Get into compliance with Quality America's OSHA Safety Program Manual and stay in compliance with OSHA Watch Newsletter...

    Most Popular

    Related Articles