AAAHC “The Accreditation Association”

1. AAAHC “The Accreditation Association” Selecting an Accrediting Body Carolyn Kurtz, JD July 23-24, 2007

2. Why is Accreditation Sought? • Public Recognition • Marketing • Regulatory Compliance • Reimbursement • Consultative Guidance • Quality Improvement • Specialty Society Requirements • Increasing Consumer Awareness • Media Influence

3. 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.

4. 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.

5. 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.

6. 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.

7. 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

8. 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

9. 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

10. 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

11. Continual Growth FY ‘00/‘01 – ‘05-‘06

12. 75% Growth inAccredited ASCs

13. 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

14. 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

15. The AAAHC Accreditation Program

16. 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

17. AAAHC Standards Outcome statements that reflect the characteristics that AAAHC requires of an accreditable ambulatory health care organization.

18. 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

19. Surveyors • 312 “volunteer” surveyors nationwide • Professionals who are actively involved in or have extensive experience with ambulatory health care, including: • Physicians • Dentists • Registered Nurses • Administrators • Surveyors receive initial credentialing/training • Re-trained/Re-credentialed every 2/yrs • Oversight provided by Surveyor Training and Education Committee

20. Pre-Survey/Application Process • Submit Application and Supporting Documentation • Examples of Documentation • Organizational history • Mission statement • Articles of Incorporation/Bylaws • Statement of Patient Rights/Responsibilities • Credentialing Policy • QI Program Description • Emergency Plan

21. Types of Surveys • Early Option • Consultative • Initial • Random • Discretionary • Medicare Deemed Status

22. 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

23. 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

24. Accreditation Decisions • Three year • One Year • Six Months • Deferral • Denial/Revocation

25. Commitment to Quality AAAHC Institute for Quality Improvement 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.

26. AAAHC “The Accreditation Association” Phone: 847-853-6060 Web site: www.aaahc.org E-mail: info@aaahc.org