AAAHC Releases 2023 Quality Roadmap


AAAHC Releases 2023 Quality Roadmap

The Accreditation Association for Ambulatory Health Care (AAAHC) of Deerfield, Illinois, released its 2023 AAAHC Quality Roadmap, a comprehensive analysis of data from nearly 1,800 accreditation surveys conducted in a cross section of organizational types from January 2022 to February 2023, according to a release. The annual report outlines opportunities and challenges for ambulatory healthcare providers and helps providers identify themes that deserve special attention as organizations pursue ongoing quality improvement throughout the accreditation cycle.

“Every year, our analysis provides valuable information for ambulatory facilities to evaluate their performance and determine measures they may take as part of their accreditation journey,” said Noel Adachi, president and chief executive officer of AAAHC, in the release. “We encourage healthcare facilities to use this data and accompanying analysis to guide decision-making and start conversations about how to implement best practices now and throughout the 1,095 days of their accreditation term.”

The Quality Roadmap provides in-depth insight based on data from surveys of organizations seeking initial or reaccreditation in the Ambulatory Accreditation (AMB) and the Medicare Deemed Status (MDS) programs. Organizations surveyed include ASCs, office-based surgery practices (OBS) and primary care settings (PC). OBS settings include diagnostic imaging centers, fertility centers, oncology centers and office-based anesthesia organizations.

This report provides an analysis of the highest and the lowest compliance findings for those standards that were applicable to at least 95 percent of the organizations surveyed.

Findings on High Deficiency Standards

Data show that healthcare facilities can continue to strengthen operations and survey readiness by improving key standard processes. Although the observed deficiencies, such as personnel and quality of care, are similar to previous years' findings, a few critical areas related to emergency preparedness, documentation management, and credentialing and privileging require dedicated facility attention with specific considerations and strategies to address current national labor shortages, according to the release.

Findings on High Compliance Standards

In addition to high deficiency standards, the Quality Roadmap also indicates that accredited organizations have shown sustained compliance or notable improvement in several key areas:

Ambulatory Status Standards

  • Meeting at least annually, or more frequently as determined by the governing body, to discuss key business matters.
  • Providing and supporting ongoing professional development for staff.
  • Maintaining written procedures for managing medical emergencies and unplanned outcomes for which transfer to a higher level of care is indicated to treat patients.
  • Complying with national patient confidentiality standards for medical documentation.
  • Ensuring patients receive proper individual clinical records, when applicable.
  • Documenting and investigating workplace injuries and illnesses, when applicable.

Medicare Deemed Status Standards

  • Complying with regulations that meet requirements for emergency service payment.
  • Ensuring that organizations protect the confidentiality of an individual’s health records and personal information.
  • Appointing qualified physicians, dentists, etc. to supervise surgical procedures on-site.
  • Maintaining written policies regarding procedures and treatments offered to patients.
  • Providing patients with comprehensive postoperative care and discharge instructions, when applicable.
  • Ensuring pharmaceutical services are directed by a qualified, licensed professional.

Leveraging the Quality Roadmap in Your Facility

The report is designed to help providers understand common deficiencies and compare these findings to their most recent on-site report and annual self-assessment. Facilities are encouraged to share and discuss findings with others in the organization to help drive decision-making on possible quality improvement studies or other corrective action, according to the release. Additional guidance addresses patient safety tool kits and other AAAHC resources to improve and ensure quality. Specifically, AAAHC recently revised tool kits to help organizations establish, reevaluate, and/or improve their credentialing and privileging and emergency preparedness, and new surgical considerations for obesity and obstructive sleep apnea.

“The Quality Roadmap is an essential industry tool to ensure that accredited organizations can allocate resources to celebrate their success as well as prioritize and address noted deficiencies and areas for improvement,” said Julie Lynch, RN, director of Institute for Quality Improvement, in the release. “This report uses a data-lead approach to address ongoing deficiencies, such as documentation and emergency preparedness, by providing process guidelines, digital tools and educational opportunities for healthcare providers.”

Download the Quality Roadmap at