For AAAHC, quality improvement (QI) refers to the use of a reliable, repeated process to initiate and sustain improved performance over time. Sometimes organizations approach Standards related to QI with trepidation. The AAAHC Institute for Quality Improvement works to make the Standards easier to understand and implement through tools and resources.One of these tools is the “10 Elements of QI,” which forms the basis of a number of Standards found in Chapter 5 of the

Accreditation Handbook taken as a whole, the activities described by the 10 Elements become the steps in a QI study.

Element 1: The purpose

Action to take: Think about a potential problem. Describe it, why you think it is an issue, and why it matters to your

organization. Is it because:

•Itthreatenspatientsafety?

•You’vehadpatientcomplaintsaboutit?

•Itcostsyou,yourpatients,and/oryourpayers?

•Otherpeople(insideoroutsideyourorganization)seemtobedoingitdifferently?

•Someotherreason?

(continued on page 3)

Bringing quality improvement to life

UpdateFall 2012

Improving Health Care Quality through Accreditation

A publication of the Accreditation Association for Ambulatory Health Care, Inc.

Improving Health Care Quality through Accreditation 2

Like most of the Board leaders

before me, my first exposure

to the AAAHC came from

standing on the organization

side of a survey. For 30 years

I worked at the University of

Washington, the last 18 as an

administrator for Hall Health

Primary Care Center. This was

a large medical group practice

with 17 physicians and 7 nurse practitioners seeing about

500 patients a day. It was during our second AAAHC

survey that Dr. Maggi Bridwell—such a force for the

positive impact of accreditation on quality—suggested

that I become a surveyor.

That’sthebeginningofmylonghistorywithAAAHC.

After training and gaining experience as a surveyor,

I was asked to join the Accreditation Committee. This is

the group that reviews the findings of the surveyors and

makes the ultimate decision about accreditation for each

organization. I thought it would be a great educational

experience and make me a better surveyor and report

writer. Several years later I was asked to chair the

committee which I did for many years.

I joined the AAAHC board in 2004 as one of two

representatives of Medical Group Management Association

(now MGMA-ACMPE) of which I have been a member

since 1972. About 4 years ago, I was nominated and

elected to the position of AAAHC secretary. The following

year I was elected treasurer, then vice president and I

became chair of the board in April 2011. I am proud to be

the second woman, after Dr. Bridwell, to hold this position.

I have several specific goals for the board during my tenure.

I’veappointedacommitteetostudytheefficiencyand

effectiveness of the entire survey process. Just as we

require measurable quality improvement of our accredited

organizations, we demand it of ourselves as well.

It is a big task and the committee is working hard at this.

A second goal is to complete a succession plan for

AAAHC. This is a much needed way of ensuring that

we have the right infrastructure to support growth and

change. We need to retain leadership agility in an evolving

health care environment. The charge for this committee

was initiated by my predecessor, Jack Egnatinsky, MD.

Our current vice-chair, Peg Spear, MD, is overseeing the

completion of the work which is scheduled to come before

the board for approval in November.

My personal goals include balancing the opportunity

to represent the business interests of AAAHC with my

work as a surveyor. Now, I am answering questions and

addressing the concerns of our many constituents while

continuing to survey ASCs, GI centers, college and Indian

health centers. I absolutely enjoy this work. s

Karen McKellar

AAAHC Board Chair

A message from the Board Chair

AAAHC Board Chair, Karen McKellar, lives on Lake Chelan in Washington in a cabin accessible only by boat or float plane. Despite a decidedly rural base, she surveys 8 to 12 organizations seeking accreditation each year.

Element 2: The goal

Action to take:Yourperformancegoalshouldbe

appropriate and realistic. A benchmark may be available

in the literature or through a study in which you are

participating. State that you want your organization to

meet the benchmark and what it is.

Ifyoucanfindnobenchmarkandyourorganization’s

performanceisn’twithin10%ofperfect,setapercentage

goal to improve within a specified time. The farther your

organization’sperformanceisfromperfect,thehigher

a percent you choose to improve performance and the

longer the period of time you will need to do this.

Element 3: Description of data

Action to take: Look forward to describe the plan—what you

will do to get the information (data) you need to determine if

you have an issue. Include:

•Whatyouaremeasuring.

•Whereyou’regettingthedata.

•Whatyou’reusingtocollectdata.

•Whoyou’retargetingwithyourdatacollection:patients

(gender, age, medical condition, procedure), providers

(with certain types of patients or procedures), schedulers,

billing personnel, etc.

•Whowillcollectthedataandforhowlong.

•Whateverelseisnecessaryforsomeonetounderstand

how you did this.

Element 4: Evidence of data collection

Action to take: Look back to describe what happened.

Include:

•Thespecificperiodoverwhichyouactuallycollecteddata.

•Thenumberofvisits,procedures,patients,orcharts

from which you collected data.

•Theactualdatayoucollected.

Element 5: Data Analysis

Action to take:

Describe your analysis

and summarize your actual data using averages, ranges, or

percentages.

•Helpothersunderstandyourdatathroughtables

or charts.

•Includeinformationabout:

– Frequency: How often the issue occurs in your study

period—this will probably be a percentage of charts,

surveys, interviews, etc.

– Severity: A patient safety issue may not occur very often

(see Frequency above), but the implications could be so

severe (potential loss of life or disability, lawsuits, etc.)

that you would report the severity or potential severity.

– Sources: Potential reasons for your issues (e.g., patient

wait times vary with your arrival time instructions to

patients,orinformationfromabenchmarkingstudy’s

bestperformersaboutprocesses/proceduresthatdiffer

from yours.)

Element 6: Comparison of actual to goal

Action to take: Report your performance goal, your

current performance, and whether or not you met the goal.

If your current performance meets the goal, stop here and

choose a new potential problem. You have not a completed

quality improvement study because you have not improved

quality--you have only measured it.

Element 7: Corrective actions

Actiontotake:Ifyouhaven’tmetyourperformancegoal,

usewhatyou’velearnedthroughdatacollectiontobegin

corrective actions. These might include:

•Adoptingbenchmarkbestperformers’processes/

procedures.

3Fall 2012

Bringing quality improvement to life (continued from first page)

(continued on page 4)

Improving Health Care Quality through Accreditation

•Datashowingthatwhenoneissue(e.g.,arrival

instructions or anesthesia type) varies or changes, the

issue you are studying (patient wait times or discharge

times, respectively) varies.

•Issuesyouhaven’tmeasured,butthatarelikelytohave

an influence on the data (e.g., provider late arrival and

patient wait times).

Then describe:

•Thetargetoftheintervention(patient,doctor,scheduler,etc).

•Whatitis(usingchartand/orpatientreminders,posters,

education sessions, etc).

•Howlongyouwillgivetheinterventiontowork.

Element 8: Re-measurement

Action to take: Use the data collection process you

described in Element 4. Use the new data to perform the

analyses you described in Element 5. Repeat Element 6.

Ifyoustillhaven’tmetyourgoal,gotoElement9.

If you have met the goal, go to Element 10.

Element 9: Additional corrective action

Action to take: Try additional interventions using the

same process described in Element 7. Repeat the steps

in Element 8.

Element 10: Communication of results

Action to take: Describe how the results of your study were

reported to the Governing Body and refer to meeting minutes.

Describe how the results were presented to others and

refer to the documentation (personnel files, in-service sign

in sheets, meeting agendas and minutes).

Organizations seeking accreditation are not required to

use the 10 Element format for their study reports, but the

format does make it easy for both the organization and the

surveyor to rapidly review and ensure that each element is

included.

In other words, the 10 Elements can make your job and the

surveyor’sjobeasier.

Benchmarking can also make your job easier—contact us

for more information. s

Bringing quality improvement to life, continued from page 3

Quality

4

Quality Improvement and Benchmarking: A Workbook of Strategies and tools for Success covers the 10 Elements in greater detail and at a beginner and advanced level.

Innovations in Quality Improvement Compendium is a collection of award-winning QI projects.

Quality Improvement Insights is a compilation of white papers focused on specific QI topics.

5Fall 2012

At Lincoln Surgical Hospital, in

Lincoln, NE, Jan Kleinhesselink

describes her work as “educating

our staff on what quality looks like

in action.” Her role requires that she

stay current on “all things regulatory”

andit’sherenthusiasmforthecycle

of continuous learning and teaching

that distinguishes her as a surveyor for AAAHC.

“I was an OR nurse in an ambulatory surgery center

that evolved into a surgical hospital and management

group,” Jan explained. “I was asked to help our managed

ASCs prepare for accreditation. That led to a lot of staff

education and mock surveys. Our centers were accredited

byAAAHCbutI’dalsobeenthroughsurveyswithanother

accreditor, so I was familiar with several different

approaches to the process.”

On AAAHC surveys, she found a fact-finding, success-

oriented approach that strongly correlated with her own

interest in quality improvement. On one of those occasions,

AAAHC surveyor Karen Connolly asked if Jan had ever

considered becoming a surveyor herself. She had, in fact,

butatatimewhenAAAHCwasn’tacceptingapplications.

When Karen approached her, the application process was

open, so Jan applied, was invited to training, and partici-

pated in her first mentored survey in the spring of 2009.

Since then, she has been credentialed to conduct

Medicare deemed status surveys, served as an instructor

at QI-focused programs, acted as a facilitator of break-out

groups at Achieving Accreditation, and joined the board

of the Institute for Quality Improvement.

As a surveyor, Jan keeps in mind the range of her

own experiences with different accreditors and strives

to be as transparent as possible with each organization

she surveys.

“My goal is to leave them with full information. If they

can’tprovidemewithawrittenpolicy,I’llaskthemto

describe their process. The more I understand about how

they do things, the more likely it is that I can share a useful

resource.IofferasmuchastimeallowswhileI’monsite

and I write a lot on my survey reports.”

Jan continues to be most interested in education on

quality improvement.

“I think that sometimes people struggle with the premise

of QI. They often approach it as strictly regulatory –

somethingtheyhavetodo.Butit’snotaboutcollecting

data,it’saboutimprovingresults.”

“That being said, process change can be extraordinarily

challengingifyoudon’thavebuy-inandcommitment.

Thosecomefromhavingasenseofwhyyou’remaking

the change – to do it better. Understanding that was really

my aha moment.”

Jan works to bring that moment of clarity to others, both

within her own organization as Chief Quality Officer, and

to the organizations she surveys for AAAHC. “Being a

surveyor has helped me grow as a professional. It has

broadened my mind to the fact that there are a lot of

ways to do things well.” s

Surveyor SpotlightJan Kleinhesselink, RN, BSHM

Improving Health Care Quality through Accreditation

(continued on page 7)

6

Meet the AAAHC StaffGeoffrey Charlton-Perrin

With his hyphenated name and

patrician British accent, one might

mistake Geoffrey Charlton-Perrin

for a very serious person. And he is

serious – about building the AAAHC

brand, about making art, and about

keeping work and life interesting.

Geoffrey’searlycareerinadvertisingincludedhandling

marketing for clients ranging from S.C. Johnson to Blue

Cross Blue Shield. He rose to lead the Chicago office of

the Della Femina McNamee agency, then detoured to the

Chicago Convention & Tourism Bureau before exploring

an interest in associations and joining AAAHC in 2008.

“I was interviewing with John Burke,” Geoffrey recalled,

“and he asked me why I was interested in coming to a

muchsmallerorganization.I’vealwaysfeltthatapplying

the principles of marketing is really the same whether

you’reinalargeorsmallofficebutthemostfunand

excitement is when you have the opportunity to do

more, to be a jack-of-all-trades.”

Building our brand

Today, he continues to be engaged in his role as Director

of Marketing & Communications. In that capacity,

Geoffrey has had a hand in everything from strategic

planning retreats to producing videos to writing copy

for advertisements and brochures. The marketing

department, under his guidance, develops messaging

and adapts it to distinct market segments through a

range of strategies including advertising, social media,

speaking engagements, and editorial coverage. The

departmentalsomanagestheproductionofeachyear’s

suite of Accreditation Handbooks, and develops and

executes materials for the AAAHC Institute for Quality

improvement and the Accreditation Association for

Hospitals and Health Systems.

Geoffrey has been deliberate about building a family look

and feel for the previously disparate materials that we use

to tell our story.

“Any good marketer wants synergy,” he explained.

“It takes multiple contacts to transform an unaffiliated

stranger into a customer. By unifying our message across

all media, we can use a variety of channels to effectively

speed that process.”

Geoffrey refines that message by meeting AAAHC

customers (and potential customers) across the country.

He often staffs the AAAHC exhibit booth at professional

conferences, giving him the opportunity to learn about

and from the variety of organizations we accredit. These

face to face interactions help reveal the kinds of information

they value. And while there is tremendous diversity in

ambulatory health care, organizations that want to accredit,

hesays,sharetwocharacteristics:They’redrivento

excellence and they embrace the validation that a

peer-reviewer provides.

His artistic process

Geoffrey is also an accomplished writer and artist and his

approach to building the AAAHC brand is much the same

Hello

Meet the AAAHC Staff, continued from page 6

Lt. Col. Kimberly Merritt named AAAHC-U.S. Air Force Fellow

AAAHC provides an annual fellowship that supports

the training of an active duty Air Force officer in the

requirements, processes and procedures of AAAHC

accreditation. Lt. Col. Kimberly Merritt has been

selected for the 2012-2013 fellowship period, joining

the AAAHC staff in August.

During her tenure as Fellow, Lt. Col. Merritt will be

working closely with Accreditation Services staff to

gain first-hand knowledge of the what and how of a

accreditation, as well as the rationale and background

used to design the Standards and survey process. This in-

formation will be used to improve understanding of AAAHC

Standards across the Air Force Medical Service (AFMS).

After her fellowship year, Lt. Col. Merritt will be equipped

to assume an internal consultant position within the

AFMS, acting as an educational resources and interpreter,

and liaison between the AFMS and the AAAHC. s

News briefs

Fall 2012Fall 2012 7

Our final educational program of the year will take place at the Bellagio in Las Vegas. In addition to an overview of the current 2012 Standards, this is an opportunity to get an in-depth look at the final Standards that will be released for 2013.

Special program for health plan administrators

A seminar focused on health plan accreditation will run concurrently with Achieving Accreditation. This program will cover the Standards that will become effective January 1, 2013 for health plans seeking accreditation. experienced surveyors will address:

•MemberRights,Responsibilities&Protection•GovernanceandAdministration•ProviderNetworkCredentialing•CaseManagement&CareCoordination•QualityImprovementandManagement

Achieving Accreditation in Las Vegas•ClinicalRecords•EnvironmentofCare&Safety•HealthEducation&WellnessPromotion•StandardsforSpecialServices:Behavioral

Health and Dental

November 30-December 1

Bellagio, Las Vegas, NV

Find more information and register online at www.aaahc.org.

as his approach to making art. He

begins with a broad concept and a

rough sketch, but refines his product

by staying open to new decisions

as the project progresses. In other

words, he is a problem solver.

“When I was about 13, I encountered

the limited democracy of an English

Brunnhilda,2002.Paintedwood.GeoffreyCharlton-Perrin’swork emulates the whimsical, naive qualities of folk art objects in a contemporary way.

high school,” he related, “with the single elective choice

of art appreciation, music appreciation, or woodworking.”

“I figured I could learn to appreciate art and music on my

own, but that woodworking would really require a teacher.

Later, as the father of young children, I started building

some furniture and toys for my sons. Just projects that

I thought would be fun and that they would like.”

And this has been his career path, as well: following

creative opportunities as they present themselves and

looking for fun. s

Association of Military Surgeons of the United StatesNovember 12-14, Phoenix, AZ

Texas ASC AssociationNovember 15-16, Dallas, TX

Update5250 Old Orchard Road, Ste. 200Skokie, Illinois 60077

Update Fall 2012

10/12/7K© The Accreditation Association for Ambulatory Health Care. Reuse is allowed with credit to “The Accreditation Association Update newsletter” or www.aaahc.org.

Fall 2012

A publication of the Accreditation Association for Ambulatory Health Care, Inc.

Please visit us at these upcoming conferences:MGMA-ACMPEOctober 21-24, San Antonio, TX

Becker’s ASC Conference October 25-26, Chicago, IL

New Jersey ASC Association October 26, New Brunswick, NJ

ACO CongressOctober 30-31, Los Angeles, CA