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Embracing Change,
Advancing Health
Improving Health Care Quality through Accreditation
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TABLE OF CONTENTS
Letter from CEO Dr. Stephen Martin and Board Chairman 	
Frank Chapman
6 Expanding the Mission
8 Advances in AAAHC Accreditation
10 Standards Reflect Changing Health Care Needs
12 Compassion and Caring Around the World
14 The Journey to Become CEO at AAAHC
16 The AAAHC Institute for Quality Improvement
18 Advancing Health Care via Education, Thought Leadership
20 Communicating to Constituents
22 AAAHC Leadership and Association Members
23 AAAHC Financial Summary and AAAHC Executive Staff
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LetterFrom CEO Dr. Stephen Martin and
Board Chairman Frank Chapman
One of the seven guiding principles that serves as
the foundation for our mission at AAAHC is“a commitment
to embrace changes in the health care landscape and
proactively adapt to meet client needs with innovative,
creative solutions.”
In 2015, such changes indeed were a focus. We implemented
a number of new and evolving initiatives. The following
pages describe the details; here are several highlights:
• Our sister organization, the Accreditation Association
for Hospitals and Health Systems (AAHHS), purchased
the Health Facilities Accreditation Program (HFAP) 		
from the American Osteopathic Association (AOA). With
the acquisition of HFAP, the oldest hospital accreditor in
the country, AAHHS significantly broadens its services
to include behavioral health, laboratory and certification
for stroke and lithotripsy.
• We now are the largest accreditor of employer
health care networks in the country, a testament
to the consultative, peer-based approach AAAHC
offers. This reflects our response to the increasing
number of multi-site organizations that deliver
employer-based health care.
• We extended our reach to address the growing
need to accredit health plans. We received formal
recognition from three additional state
governments (Arizona, Illinois and Minnesota)
to provide health plan accreditation. Under the
Patient Protection and Affordable Care Act, an
insurer must be designated as a Qualified Health
Plan to be included in a state or federal exchange,
and accreditation is a requirement.
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• To further underscore the valuable role we play
in helping set the agenda for quality improvement,
we renamed the comprehensive data analysis
report issued annually by the AAAHC Institute for
Quality Improvement. This outstanding resource
is now called Quality Roadmap to reflect how
it lays out meaningful paths and guideposts for
the ambulatory health care community to further
improve patient safety.
Such examples illustrate what we have done and
will continue to do: We make changes in our own
approaches and methods to constantly improve.
As you can see along the bottom of the page, we are
responding to the ever-changing health care landscape
through organizational divisions that address specific
settings and needs.
Our structure enables us to deliver the targeted
tools and education most relevant to our clients.
Accrediting bodies must create meaningful, adaptive
accreditation programs for the many new facets of
health care. That’s the best and most effective way
we embrace change.
What won’t change is the personal engagement and
passion all our team members possess to help meet
our mission and bring the growing value of the
peer-based accreditation process to health care
organizations.
Stephen A. Martin, Jr., Ph.D., M.P.H.,
President & CEO	
Frank J. Chapman, MBA,
Board Chairman
“Accrediting bodies must create meaningful,
adaptive accreditation programs for the many
new facets of health care.”
EXPANDINGTHE MISSION
AAAHC and our sister organizations continuously seek ways to improve health care quality
through accreditation. While many know us best for our work with ambulatory facilities in
the United States, we are active in a variety of health care settings including hospitals,
international facilities and health plans.
“Maintaining full AAAHC accreditation has been
a key ingredient to our success and in providing
quality health care services to our members.”
- Gale Lam, Chief Operating Officer, HealthSun Health Plan
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AAHHS Acquires Health Facilities Accreditation Program
In October we acquired the Health Facilities Accreditation Program (HFAP) from the American
Osteopathic Association (AOA). This unprecedented transaction received approval from the Centers
for Medicare and Medicaid Services (CMS), enabling, for the first time, two accrediting organizations
to transition into a single ownership.
HFAP accredits more than 400 acute care hospitals, critical access hospitals and laboratories,
and has maintained continuous deeming authority since the inception of CMS in 1965, making
it the oldest hospital accreditor in the country. The acquisition is part of our growth strategy to
bring health care quality improvement through accreditation to a larger number of organizations
across the continuum of health care delivery.
AAHHS Accredits Its First Critical Access Hospital
In 2015, AAHHS announced its first critical access hospital accreditation, Decatur County Hospital,
in Leon, Iowa.“The first critical access hospital accreditation is a significant milestone for AAHHS
and for the future of critical access hospitals,”said Meg Gravesmill, vice president of hospital
operations for AAHHS.“We have developed our Standards collaboratively with operators of critical
access hospitals so they are designed specifically for smaller and rural facilities.”
Acreditas Global Marks First Reaccreditation
Acreditas Global, our international accreditation arm, reaccredited Aliada Contra El Cáncer, a cancer treatment
center in Lima, Peru—the first facility in the world to achieve reaccreditation from Acreditas Global under the
Standards established by AAAHC International. Acreditas Global accredits five Peruvian organizations and Peru
is a focus for additional growth in 2016.
AAAHC Becomes Largest Accreditor of Employer-Based Health Care Networks
With our November accreditation of CareATC, Inc., an Oklahoma-based provider of employer on-site clinics,
AAAHC became the country’s largest accreditor of employer-based health care. More than 89 employers
nationwide provide health care services to their employees through a network accredited by AAAHC.
AAAHC-Accredited Health Plans Demonstrate Exceptional Performance in Florida
In late 2015, CMS awarded the high ranking of 4.5 stars to four health plans in Florida for the upcoming year.
What did they all have in common? AAAHC accreditation. The highest rated plans in the state of Florida are all
accredited by AAAHC. CMS granted 4.5 star ratings nationally to only 65 Medicare Health Plans for 2016.
“Multi-site organizations succeed at providing high-quality care
because of the strength of their provider network. We’ve created
a collaborative, time-efficient way for provider networks to
demonstrate that they deliver quality patient care.”
- Stephen A. Martin, Jr., Ph.D., M.P.H. AAAHC President & CEO
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In recent years, we witnessed a surge in the diversity of health care organizations
that seek AAAHC accreditation.
Network Accreditations. In today’s changing environment, multi-site
health care organizations seek ways to effectively show their entire network
delivers quality health care. The AAAHC Network Accreditation Program (NAP)
offers a customized survey experience that focuses on the corporate organization’s
system to meet AAAHC nationally-recognized Standards at all its sites of care.
Workplace Clinics. The increased number of on-site workplace clinics
reflects corporations’efforts to keep employees healthy and productive.
Accreditation from AAAHC sends a strong message to employees that
their on-site health facilities deliver nationally-recognized Standards
of patient care.
Urgent Care Centers. With the rapid growth of urgent care centers , the public’s
acceptance of quick-access, walk-in care represents one more area where
accreditation is valuable.
Value of AAAHC Accreditation
What so many of these groups tell us is how much they value our approach
to accreditation. Our peer-based evaluation fosters a consultative, educational
survey that helps organizations improve care, services and efficiency.
AAAHC Accreditation is an achievement that:
√ Demonstrates a commitment to high-quality care
√ Promotes a culture of continuous improvement
√ Signals excellence to patients and the community
√ Satisfies regulatory requirements
√ Attracts high caliber staff
√ Facilitates third-party reimbursements
√ Creates a competitive advantage
“We constantly strive to raise the bar within our organization,
especially in the realm of care delivery. Achieving AAAHC
Network Accreditation affirms our effort to provide our
patients with the highest standards of care available.”
- Jackie Hope, RN, BSHA, Director of Quality, CareATC, Inc.
ADVANCESIN AAAHC ACCREDITATION
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Accredited Organizations Abound
The universe of organizations AAAHC
accredits is broad and varied. They include:
• Ambulatory Surgery Centers
• College and University Health Centers
• Community Health Centers
• Dental Group Practices
• Dental Homes
• Diagnostic Imaging Centers
• Endoscopy Centers
• Health Plan/Managed Care Organizations
• Immediate/Urgent Care Centers
• Indian Health Centers
• International Organizations
• Lithotripsy Centers
• Medicaid Plans
• Medical Group Practices
• Medical Homes
• Medicare Advantage Plans
• Military Health Clinics
• Multi-site Organizations
• Occupational Health Clinics
• Office-Based Surgery Centers
• Retail Clinics
• Specialty Services
(e.g., radiology, dialysis and anesthesia)
• Women’s Health Centers
• Workplace On-site Clinics
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More than
6,000organizations
display the AAAHC Certificate
of Accreditation.
148new organizations
earned AAAHC accreditation
in 2015.
STANDARDSREFLECT CHANGING HEALTH CARE NEEDS
The AAAHC Standards Committee is charged with monitoring Standards and making revisions
to ensure they continue to be relevant, reflect the rapid changes in health care and comply with
regulatory developments.
This year’s report theme,“Embracing Change, Advancing Health Care,”truly captures the AAAHC
team’s ongoing efforts to establish and update Standards to best address quality goals and
patients’needs.
What sets AAAHC apart from others in our field is the unique collaborative approach that
incorporates input, insights and information from a broad-based team of association members,
accredited organizations and the surveyors who work in health care daily as physicians, nurses,
administrators and in other vital roles.
A Distinct Perspective
The beauty of this approach is that while AAAHC Standards are based on best practices, they are
written in a way that enables compliance while still meeting the often unique needs of individual
health care settings.
In 2015, AAAHC embarked on a major initiative to develop“interpretative guidelines”to enhance
the way we describe Standards to constituents. We began a comprehensive process to review
the intent of each Standard. Our goal? Improve language where necessary and be more clear,
concise and consistent. Special attention was given to Standards identified as new or particularly
challenging for interpretation.
This far-reaching endeavor continues in 2016 to further ensure Standards are communicated in the
most effective and meaningful manner.
Additional Significant 2015 Accomplishments
Among other efforts conducted in 2015 to improve health care quality and foster patient safety:
• Updated Standards for diagnostic imaging, laboratories and lithotripsy sites.
• Focused significant attention, as in past years, on Standards that cover infection
prevention and control.
“When you visit an organization as a surveyor
for AAAHC, the staff will really share everything.
And it’s all for the good old fashioned reason that
they want to improve quality. That’s inspiring.”
- Dennis Schultz, MD, MSPH, AAAHC Surveyor
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“My catch phrase to new surveyors is ‘what does the Standard
say?’It reminds them they should educate themselves and the
organizations they survey about the basis and intent of the
Standards, engage with the organization’s staff to understand
how they meet the Standards and share alternatives.”
- Alsie Fitzgerald, RN, CASC, AAAHC Surveyor
Traveling Miles for Smiles
AAAHC surveyor Dr. Jeff Moses always loved his work as a craniomaxillofacial
surgeon in the U.S., but sought a way to help children in other parts of the world
without access to such care. Dr. Moses volunteered to treat children with facial
deformities, usually cleft lips and palates.
In 2005, Dr. Moses and his wife Maribel established the non-profit Smiles
International Foundation which, for more than 10 years, has treated thousands
of children in Costa Rica, Mexico, India, Ukraine and other countries.
Treatment for cleft lips and palates requires three or four surgeries, so the teams
of volunteers return to the same villages for several years.
COMPASSIONAND CARING AROUND THE WORLD
“Many babies born with this deformity are
shunned or face ridicule until we complete
treatments. We give them self-esteem,
happiness and they are accepted as normal
human beings. These children deserve that.”
- Dr. Jeff Moses
After Surgery, They Can See Again
Mary Sibulsky has been a surveyor for AAAHC since 2007 and she
taps her organizational skills as a manager of an ophthalmology
center in Idaho to coordinate volunteer medical missions to
Central America.
The non-profit International Eye Institute that she and a team of
doctors created provides adult and pediatric eye care and surgery
to people in impoverished areas. Cataract extraction is a frequent
procedure for helping those who are blind or nearly blind.
“Many of these patients plan for months
to attend our clinics – traveling by bus
across borders or walking barefoot for days.
We help change their lives and it’s a joy
to provide this care.”
- Mary Sibulsky
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Medicine is people caring for people. For many of our folks, this dedication goes beyond a commitment to
their own practice and accreditation work. They often devote their time to help others in need. Here are five
stories of their inspiring work.
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A Legacy of New Faces
For Noreen DiPlacido, a long-time surveyor and RN, a semi-annual pilgrimage
to Honduras with a group to provide dental and oral care to villagers that
began in 1997 has now become a legacy. The group worked in remote areas
with no electricity or running water and little in the way of equipment.
Noreen, her husband Frank and their team then established New Faces for
Honduras, an organization that sets up camps in small villages, treating
thousands of in-need patients, many who had never seen a physician or health
care worker. In partnership with other organizations, New Faces for Honduras
now treats 30 to 35 major cases twice a year.
“We also sponsor dental students financially and, at times,
bring patients to the U.S. for treatment. It’s truly rewarding
to know our valuable work continues.”
- Noreen DiPlacido
A Humbling Experience
Dr. Michael Huey, an associate professor of family and preventive
medicine at Emory University School of Medicine and a surveyor
for AAAHC, took an unexpected long journey last summer. He strung
together vacation time and work days to spend four weeks in Sierra
Leone, one of the countries most affected by the unprecedented
Ebola outbreak.
As a member of the CDC Ebola West African response team, Dr. Huey
toured health facilities, provided infection control recommendations
and taught infection control classes for health care workers, ambulance
drivers and crew and burial teams.
“When my family immigrated to Chicago, I was 16 and did
not speak a word of English. West Town was where I took my
‘first steps.’It is so satisfying to help patients when they can’t
communicate their needs or concerns.”
- Dorota Rakowiecki
“It was profoundly humbling to witness the dedication
and bravery of the health care workers who fought this
terrible disease for more than a year. The world owes
them a tremendous debt of gratitude.”
- Dr. Michael Huey
Helping the Old Neighborhood
Dorota Rakowiecki’s volunteer work takes place much closer to home. The AAAHC
Director of Ambulatory Accreditation Operations serves as a translator for Polish
patients at the CommunityHealth clinic in Chicago’s West Town neighborhood.
CommunityHealth delivers comprehensive, high-quality, patient-centered health
care at no cost to low-income, uninsured adults in need of a medical home.
THE JOURNEYTO BECOME CEO AT AAAHC
For new AAAHC CEO Stephen A. Martin, Jr., PhD, MPH,
it’s all about the journey. His deep-rooted philosophy
sees excellence as a journey, not a destination. This applies
to his focus and vision for AAAHC to make each client’s
accreditation experience phenomenal through a
collaborative learning approach. And it’s the AAAHC
commitment to excellence that attracted the accomplished,
experienced health care professional to the organization.
The great appeal, said Dr. Martin, is that although
by its very nature AAAHC works behind the scenes,
the organization is at the forefront to help ensure
people use top-quality health care organizations.
“I like to draw a comparison to an airplane,”Dr. Martin said.
“You trust the FAA as a third party organization to verify the
plane’s safety. We do the same in health care by verifying best
practices are followed, whether they involve infection control,
the use of syringes, medical records, credentialing, proper
training and many, many other variables.”
Career Journey Multi-faceted
Dr. Martin’s career journey encompasses public health, health care management and disease-
based training and expertise as an epidemiologist, providing multi-faceted experiences ideal
for helping lead AAAHC.
Most recently, he was executive director for the Association for Community Health Improvement
at the American Hospital Association (AHA). Dr. Martin also served as the chief program affairs
officer for the Health Research & Educational Trust/AHA, the health commissioner and chief
operating officer for Cook County (Illinois) Department of Public Health, and a senior executive
with the Cook County Health & Hospitals System.
“I have touched so many disciplines in my own career,”he said.“It gives me insight on how
to best provide flexible accreditation approaches to organizations in a wide variety of health
care settings.”
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Experience Helps Respond to Industry Trends
Such background is particularly beneficial given the changes occurring in health care today,
including the continuum of care focus exemplified by the patient-centered medical home
model, the constant consolidations and acquisitions and the growing influence of population
health management.
“Accreditation is the essence of population health management,”
Dr. Martin said.“Accreditation focuses on the prevention of injuries
and illness, and addresses ways to help eliminate the transmission
of disease and infection. It should be positioned as a critical strategy
that verifies policies and procedures that meet a series of metrics.”
Another prevailing trend finds health care moving toward high-quality, low-cost settings,
and one of the biggest challenges is to meet quality improvement goals with tighter budgets.
“Providers are moving from fee-for-service to value-based contracts, and that’s where the
work we do is critical,”he said.“We consider how we can empower our clients to meet their
goals as well as industry goals within their budget constraints.”
From the AAAHC perspective, as valued and essential as performance metrics may be,
accreditation goes beyond those important data-driven analyses.
“We offer not just a‘check the box’relationship, but collaborative, peer relationships different
from others in our field,”said Dr. Martin.“AAAHC surveyors can say,‘Yes, I’m seeing the quality
metric, but let’s determine how you can best use it.’Best practice sharing happens all the time,
and it’s exciting to bring that to all of our clients.”
As he’s addressed health care challenges over the years, Dr. Martin gains much inspiration
from his father, Stephen A. Martin, Sr., who faced challenges of a different kind.
Martin Sr. gained honors and accolades in 1966 by becoming the first African American to
play any varsity sport (baseball) in the Southeastern Conference while at Tulane University,
which played its games throughout the Deep South.
“I learned how he handled this distinctive situation through his values, integrity and
discipline,”Dr. Martin said.“That’s always been a great lesson for me when faced with
challenges and changes. I can apply that today knowing that AAAHC is the right place
and this is the right time for my new journey.”
THE AAAHC INSTITUTE FOR
QUALITY IMPROVEMENT
A letter from Jan Kleinhesselink and Naomi Kuznets
A roadmap to quality improvement.
That phrase defines the essence of our mission at the AAAHC Institute for Quality
Improvement. Since its founding in 1999 as a non-profit entity, the AAAHC Institute
has been dedicated to providing resources and research to help ambulatory care
facilities attain the highest levels of performance.
We conveyed this commitment in 2015 when we changed the name of one of our most valuable tools,
the AENEID Report, to AAAHC Quality Roadmap. This comprehensive analysis identifies patterns of compliance
from the extensive AAAHC warehouse of accreditation survey data and offers guideposts on where and
how organizations can improve and excel. For example, the AAAHC Quality Roadmap 2015 identified safe
injection practices as a critical issue. The graphs on the opposite page highlight the report’s findings on
this topic and others.
Quality Roadmap data helps us prioritize and select subjects for another significant Institute initiative—our
popular patient safety and disease management toolkits. These informative, reader-friendly brochures tackle
key issues faced today by ambulatory health care organizations and offer guidance for best practices supported
by evidence-based rationale.
Our performance measurement and benchmarking studies offer another resource to help facilities attain
quality goals. For the first time in 2015, we compiled data from more than 1,700 esophagogastroduodenoscopy
(EGD) benchmarking studies to provide in-depth perspectives on best practices and procedures.
In the past year, we also honored AAAHC-accredited organizations that conducted exemplary quality studies
with our annual Bernard A. Kershner Innovations in Quality Improvement Award.
The Institute team often takes leadership roles in professional groups to share insights and gain knowledge.
For several years we have been involved with the Patient-Centered Primary Care Collaborative (PCPCC), an
influential organization devoted to Patient-Centered Medical Homes (PCMH). This past summer, we served
on the PCPCC Accreditation Work Group. We also continue to represent AAAHC and the Institute with
national groups such as the ASC Quality Collaboration, National Quality Forum and Physician Consortium
for Performance Improvement.
These efforts to deliver innovative programs and meaningful research to meet our mission will continue
at the highest of levels.
	 Jan Kleinhesselink, RN, BSHM, CPHG			 Naomi Kuznets, PhD
	 Chair, Board of Trustees					 Vice President and Senior Director
	 AAAHC Institute for Quality Improvement		 AAAHC Institute for Quality Improvement


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Compelling Results from AAAHC Quality Roadmap 2015
The Institute’s annual survey analysis, now called Quality Roadmap, revealed areas where providers are
performing highly and areas that should be addressed for quality improvements. Among those with
the overall highest deficiencies:
Clinical Performance Measurement Reports
In addition to the first Institute benchmarking report on EGD, other 2015 studies covered:
	 • Cataract extraction with lens insertion
	 • Colonoscopy
	 • Knee arthroscopy with meniscectomy
	 • Low back injection
	 • Primary care
	 • Shoulder arthroscopy
	 • Surgical/procedural services
Each report enables organizations to benchmark and learn best practices.
New Toolkits Respond to Member Needs
Patient safety toolkits address issues seen by surgery centers and primary care providers.
• A toolkit for surgery providers,“Ambulatory Surgery and Obesity in
Adults: Preventing Complications,”helps determine if surgery should
be delayed or if a referral to a hospital should be made based on
several medical conditions.
• The“Disease Management Toolkit: Adult Depression and Primary
Care”offers primary care providers best practice tools for screening
and following up with patients for depression.
Quality Improvement Award Winners
The AAAHC Institute honored Seton Hall University Health Services, South
Orange, New Jersey, with a 2015 Bernard A. Kershner Innovations in Quality
Improvement Award in the primary care category for its comprehensive
improvement study to more broadly implement alcohol screening methods
and interventions in college health centers.
Turk’s Head Surgery Center, West Chester, Pennsylvania, won a Kershner Award
in the surgical/procedural category for implementing safeguards for patients
when scopolamine patches are applied.
Overall Highest Deficiencies
For the third year in a row, AAAHC surveyors found
notable deficiencies in credentialing, privileging
and peer review policies.
Safe injection practices were a leading deficiency discovered in 2015. More than 10%
of ASCs, more than 9% of primary care organizations and more than 14% of
office-based organizations reviewed had deficiencies in safe injection practices.
Ensures that when opportunities for quality improvement are identified, the
organization takes steps to demonstrate the implementation and success of
corrective actions.
Another area that many organizations may need to address is documentation
that requires organizations to record allergies and untoward reactions to drugs
and materials in a consistently defined location.
Standard 7.I.C.2
Standard 5.I.C
Standard 6.F
Standard 2.II.D.
20%
14%
16%
13%
Teresa Conklin, APN, Family Nurse Practitioner,
at Seton Hall University Health Services,
receives the primary care QI Kershner Award.
ADVANCINGHEALTH CARE VIA EDUCATION,
THOUGHT LEADERSHIP
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We take seriously our role as health care quality leaders by commenting on
trends and offering consultation for providers seeking quality improvement.
Attendance Grows at AAAHC Webinars
Our highly-attended, surveyor-led webinars provide ongoing education
to accredited organizations. Among issues covered during the seven 2015
webinars were OSHA requirements, life safety code compliance, peer review,
internal benchmarking and more.
Proprietary Research Leads to Bylined Articles
The data featured in the 2015 AAAHC Institute study on
cataract extraction with lens insertion sparked interest
from the Review of Ophthalmology, which published a
three-page article on the topic authored by AAAHC
surveyor Kris Kilgore, RN. Articles such as these by AAAHC
members are published in leading professional journals
throughout the year.
Influencing International Audiences
Illustrating the international presence of AAAHC and its
Acreditas Global division, CEO Dr. Stephen A. Martin, Jr.,
addressed health care providers in Lima, Peru, attending
the Primer Foro Profesional de Enfermería: Acreditacíon
Internacional. Dr. Martin discussed how to use health care
accreditation as a strategy for improving public health.
Leading New Initiatives for Student Health Centers
The AAAHC-accredited New York University Student Health Center received
a grant in 2015 from the Agency for Healthcare Research and Quality to help
other university student health centers design and perform quality
improvement initiatives.
The New York University Center invited AAAHC to serve on the program’s
leadership committee and participate in a symposium on student health quality
improvement. Staff from more than 150 universities attended the symposium,
and AAAHC was the only accreditor in attendance.
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HEALTHCARE CONSULTANTS INTERNATIONAL
Consultation. Education. Resources. That’s the three-pronged program available from Healthcare Consultants
International (HCI), the AAAHC for-profit subsidiary that helps health care organizations prepare for accreditation.
Consultation. The HCI team of consultants and instructors helps organizations navigate the process
of accreditation, licensure and certification (including Medicare). HCI also provides guidance in quality
assurance, performance management, infection control, regulatory compliance and development of
new facilities.
In 2015, HCI expanded its services to health plans, including Federal Employee Health Benefit Plans.
And it expanded its Policy & Procedure offerings with a customized set of templates for student health
organizations.
Education. The cornerstone of HCI educational initiatives is a webinar series that covers all 25 chapters
in the AAAHC Accreditation Handbook for Ambulatory Health Care. For the 2015 handbook, 12 webinars
featured presentations from a host of experts.
Resources. More than 250 online tools and templates help organizations maintain accreditation, plus a
complete set of Policy & Procedures Manuals for drafting language compliant with accreditation standards.
Also available are regulatory updates and reviews of QI studies.
HCI consulting services are separate and independent from the accreditation services of AAAHC. All accreditation decisions by
AAAHC are made without regard to whether consulting services have been provided by HCI or any other organization.
“HCI met our needs and exceeded our expectations.
At the end of the day, we need to move fast in today’s
health care environment and with HCI, we accomplished
our goals.”
- Scott Anderson, COO, Prairie Spine & Pain Institute
COMMUNICATINGTO CONSTITUENTS
We are an organization built on personal relationships, and as in any good relationship,
communication is vital. We use a number of channels, digital and print, paid and earned,
to speak with our stakeholders about the benefits of accreditation and the work we are
doing to improve health care quality.
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Direct Outreach
We use Facebook, LinkedIn and Twitter to engage with organizations, employees
and industry colleagues. We also issue a Surveyor News & Education (SNE)
newsletter directly to surveyors to share news and thought leadership articles.
Placing Articles in Prominent Trade Media
Modern Healthcare, Becker’s ASC Review, Medical Economics, OR Today
and Review of Ophthalmology are just a small sample of the outlets
that featured editorial coverage of AAAHC, including multiple bylined
thought leadership articles by AAAHC executives and board members.
AAAHC and its sister divisions appeared in more than 1,100 articles in 2015.
Creating Brochures for Promising Markets
We build marketing materials that speak directly to key audiences
about our tailored offerings, such as those for employer-based clinics,
student health clinics, health plans, urgent care centers and our network
accreditation program.
Collaborating with Stakeholders for New Ad Campaign
In developing our latest advertising campaign, we convened groups
of surgery center and primary care professionals to determine messages
and images that would resonate with them. The ads are running in targeted
online and print medical trade publications.
Improving health care quality through accreditation
Contact us to learn more
847-853-6060 • info@aaahc.org • www.aaahc.org
A A A H C A C C R E D I T A T I O N{ }
It’s an opportunity to
see your organization
from the outside.
When AAAHC surveyors survey your organization,
it’s not a checklist kind of visit. It’s your fellow
professionals - physicians, nurses, administrators
- coming to help you be the best you can be.
• We are the leader in ambulatory accreditation.
• Our Standards are nationally-recognized.
• Our surveys are consultative
not just a checklist.
AAAHC
2015/2016 Board of Directors
Edward Bentley, MD, 2006
R. Bruce Cameron, MD, FACP, 2015
Frank J. Chapman, MBA, 2005
Ira Cheifetz, DMD, 2013
W. Patrick Davey, MD, MBA, FACP, 2003
Jan Davidson, MSN, RN, CPHRM, 2011
Mark DeFrancesco, MD, MBA, 2000
Meena Desai, MD, 2009
Robin J. Elwood, MD, FAAP, 2015
Ann B. Geier, RN, MS, CNOR, CASC, 2014
Richard D. Gentile, MD, MBA, 2006
Dave Hamel, DDS, 2015
Joy Himmel, Psy.D., PMHCNS-BC, LPC, 2015
George Hruza, MD, 2015
Sandra Jones, CASC, CHCQM, LHRM, MBS,
MSM, 2012
John P. Keats, MD, CPE, 2014
Lawrence S. Kim, MD, 2004
Ross Levy, MD, 2012
W. Elwyn Lyles, MD, 2011
Mark Mandell-Brown, MD, 2013
S. Teri McGillis, MD, 2006
Timothy Peterson, MD, 2009
Beverly Philip, MD, 2000
Kenneth M. Sadler, DDS, MPA, FACD,
FICD, 2005
David Shapiro, MD, 2013
James E. Schall, DDS, 2011
Dennis Schultz. MD, 1994-2003, 2009
Edwin Slade, DMD, JD, 2004
Arnaldo Valedon, MD, 2010
Mary Ann Vann, MD, 2008
Christopher J. Vesy, MD, 2011
Datesindicatebeginningyearofservice
Frank J. Chapman, MBA, Chair
Meena Desai, MD, Vice Chair
Kenneth M. Sadler, DDS, MPA, FACD, Treasurer
Arnaldo Valedon, MD, Secretary
W. Patrick Davey, MD, MBA, FACP,
Immediate Past Board Chair
2015/2016 Officers
AAAHC Association Members
ASCA Foundation
American Academy of Cosmetic Surgery (AACS)
American Academy of Dental Group Practice (AADGP)
American Academy of Dermatology (AAD)
American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS)
American Association of Oral and Maxillofacial Surgeons (AAOMS)
American College of Gastroenterology (ACG)
American College Health Association (ACHA)
American College of Mohs Surgery (ACMS)
American Congress of Obstetricians and Gynecologists (ACOG)
American Dental Association (ADA)
American Gastroenterological Association (AGA)
American Society of Anesthesiologists (ASA)
American Society for Dermatologic Surgery Association (ASDSA)
American Society for Gastrointestinal Endoscopy (ASGE)
Association of periOperative Registered Nurses (AORN)
Society of Ambulatory Anesthesia (SAMBA)
22
Leadership and Association Members
AAAHC Executive Staff
Stephen A. Martin, Jr., PhD, MPH		 President and CEO
Breian Meakens, MPA, MBA	 	 Chief Operation Officer
Michael Janniere, JD			 SeniorVice President and Chief People Officer
SergioTumang				 Chief Financial Officer andVice President, Administration
Ray Grundman, MSN, MPA, FNP-BC, CASC	 Chief Business Development Officer
Tess Poland				 Vice President, Ambulatory Operations
Naomi Kuznets, PhD			 Vice President and Senior Director, AAAHC Institute for Quality Improvement
Meg Gravesmill, MBA, MPA		 Vice President, Hospital Operations, AAHHS
Kristine Mighion, MD, MBA		 Managing Director and CEO, Healthcare Consultants International
AAAHC Financial Summary
23
Like us on Facebook at facebook.com/AccreditationAssn
Find us on LinkedIn at linkedin.com/company/2430500
Follow us on Twitter at @AAAHC_QUALITY
Watch us on YouTube at youtube.com/user/AAAHC60077/videos
Accreditation Association for Ambulatory Health Care
aaahc.org
5250 Old Orchard Road, Suite 200
Skokie, IL 60077
Tel: 847.853.6060
Fax: 847.853.9028
info@aaahc.org
AAAHC Institute for Quality Improvement
aaahc.org/institute
5250 Old Orchard Road, Suite 250
Skokie, IL 60077
Tel: 847.853.6060
Fax: 847.853.6118
info@aaahc.org
Accreditation Association for Hospitals/Health Systems
aahhs.org
142 E. Ontario St., 10th floor
Chicago, IL 60611
Tel: 312.202.8062
Fax: 312.202.8362
info@aahs.org
Acreditas Global
acreditasglobal.org
5250 Old Orchard Road, Suite 200
Skokie, IL 60077
Tel: 847.853.6060
Fax: 847.853.9028
info@aaahc.org
Healthcare Consultants International
hciconsultants.com
5250 Old Orchard Road, Suite 360
Skokie, IL 60077
Tel: 888.982.6060
Fax: 847.853.9028
info@hciconsultants.com

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AAAHC AR 2015_FINAL

  • 2. Improving Health Care Quality through Accreditation 2
  • 3. TABLE OF CONTENTS Letter from CEO Dr. Stephen Martin and Board Chairman Frank Chapman 6 Expanding the Mission 8 Advances in AAAHC Accreditation 10 Standards Reflect Changing Health Care Needs 12 Compassion and Caring Around the World 14 The Journey to Become CEO at AAAHC 16 The AAAHC Institute for Quality Improvement 18 Advancing Health Care via Education, Thought Leadership 20 Communicating to Constituents 22 AAAHC Leadership and Association Members 23 AAAHC Financial Summary and AAAHC Executive Staff 3 4
  • 4. LetterFrom CEO Dr. Stephen Martin and Board Chairman Frank Chapman One of the seven guiding principles that serves as the foundation for our mission at AAAHC is“a commitment to embrace changes in the health care landscape and proactively adapt to meet client needs with innovative, creative solutions.” In 2015, such changes indeed were a focus. We implemented a number of new and evolving initiatives. The following pages describe the details; here are several highlights: • Our sister organization, the Accreditation Association for Hospitals and Health Systems (AAHHS), purchased the Health Facilities Accreditation Program (HFAP) from the American Osteopathic Association (AOA). With the acquisition of HFAP, the oldest hospital accreditor in the country, AAHHS significantly broadens its services to include behavioral health, laboratory and certification for stroke and lithotripsy. • We now are the largest accreditor of employer health care networks in the country, a testament to the consultative, peer-based approach AAAHC offers. This reflects our response to the increasing number of multi-site organizations that deliver employer-based health care. • We extended our reach to address the growing need to accredit health plans. We received formal recognition from three additional state governments (Arizona, Illinois and Minnesota) to provide health plan accreditation. Under the Patient Protection and Affordable Care Act, an insurer must be designated as a Qualified Health Plan to be included in a state or federal exchange, and accreditation is a requirement. 4
  • 5. 5 • To further underscore the valuable role we play in helping set the agenda for quality improvement, we renamed the comprehensive data analysis report issued annually by the AAAHC Institute for Quality Improvement. This outstanding resource is now called Quality Roadmap to reflect how it lays out meaningful paths and guideposts for the ambulatory health care community to further improve patient safety. Such examples illustrate what we have done and will continue to do: We make changes in our own approaches and methods to constantly improve. As you can see along the bottom of the page, we are responding to the ever-changing health care landscape through organizational divisions that address specific settings and needs. Our structure enables us to deliver the targeted tools and education most relevant to our clients. Accrediting bodies must create meaningful, adaptive accreditation programs for the many new facets of health care. That’s the best and most effective way we embrace change. What won’t change is the personal engagement and passion all our team members possess to help meet our mission and bring the growing value of the peer-based accreditation process to health care organizations. Stephen A. Martin, Jr., Ph.D., M.P.H., President & CEO Frank J. Chapman, MBA, Board Chairman “Accrediting bodies must create meaningful, adaptive accreditation programs for the many new facets of health care.”
  • 6. EXPANDINGTHE MISSION AAAHC and our sister organizations continuously seek ways to improve health care quality through accreditation. While many know us best for our work with ambulatory facilities in the United States, we are active in a variety of health care settings including hospitals, international facilities and health plans. “Maintaining full AAAHC accreditation has been a key ingredient to our success and in providing quality health care services to our members.” - Gale Lam, Chief Operating Officer, HealthSun Health Plan 6 AAHHS Acquires Health Facilities Accreditation Program In October we acquired the Health Facilities Accreditation Program (HFAP) from the American Osteopathic Association (AOA). This unprecedented transaction received approval from the Centers for Medicare and Medicaid Services (CMS), enabling, for the first time, two accrediting organizations to transition into a single ownership. HFAP accredits more than 400 acute care hospitals, critical access hospitals and laboratories, and has maintained continuous deeming authority since the inception of CMS in 1965, making it the oldest hospital accreditor in the country. The acquisition is part of our growth strategy to bring health care quality improvement through accreditation to a larger number of organizations across the continuum of health care delivery. AAHHS Accredits Its First Critical Access Hospital In 2015, AAHHS announced its first critical access hospital accreditation, Decatur County Hospital, in Leon, Iowa.“The first critical access hospital accreditation is a significant milestone for AAHHS and for the future of critical access hospitals,”said Meg Gravesmill, vice president of hospital operations for AAHHS.“We have developed our Standards collaboratively with operators of critical access hospitals so they are designed specifically for smaller and rural facilities.”
  • 7. Acreditas Global Marks First Reaccreditation Acreditas Global, our international accreditation arm, reaccredited Aliada Contra El Cáncer, a cancer treatment center in Lima, Peru—the first facility in the world to achieve reaccreditation from Acreditas Global under the Standards established by AAAHC International. Acreditas Global accredits five Peruvian organizations and Peru is a focus for additional growth in 2016. AAAHC Becomes Largest Accreditor of Employer-Based Health Care Networks With our November accreditation of CareATC, Inc., an Oklahoma-based provider of employer on-site clinics, AAAHC became the country’s largest accreditor of employer-based health care. More than 89 employers nationwide provide health care services to their employees through a network accredited by AAAHC. AAAHC-Accredited Health Plans Demonstrate Exceptional Performance in Florida In late 2015, CMS awarded the high ranking of 4.5 stars to four health plans in Florida for the upcoming year. What did they all have in common? AAAHC accreditation. The highest rated plans in the state of Florida are all accredited by AAAHC. CMS granted 4.5 star ratings nationally to only 65 Medicare Health Plans for 2016. “Multi-site organizations succeed at providing high-quality care because of the strength of their provider network. We’ve created a collaborative, time-efficient way for provider networks to demonstrate that they deliver quality patient care.” - Stephen A. Martin, Jr., Ph.D., M.P.H. AAAHC President & CEO 7
  • 8. In recent years, we witnessed a surge in the diversity of health care organizations that seek AAAHC accreditation. Network Accreditations. In today’s changing environment, multi-site health care organizations seek ways to effectively show their entire network delivers quality health care. The AAAHC Network Accreditation Program (NAP) offers a customized survey experience that focuses on the corporate organization’s system to meet AAAHC nationally-recognized Standards at all its sites of care. Workplace Clinics. The increased number of on-site workplace clinics reflects corporations’efforts to keep employees healthy and productive. Accreditation from AAAHC sends a strong message to employees that their on-site health facilities deliver nationally-recognized Standards of patient care. Urgent Care Centers. With the rapid growth of urgent care centers , the public’s acceptance of quick-access, walk-in care represents one more area where accreditation is valuable. Value of AAAHC Accreditation What so many of these groups tell us is how much they value our approach to accreditation. Our peer-based evaluation fosters a consultative, educational survey that helps organizations improve care, services and efficiency. AAAHC Accreditation is an achievement that: √ Demonstrates a commitment to high-quality care √ Promotes a culture of continuous improvement √ Signals excellence to patients and the community √ Satisfies regulatory requirements √ Attracts high caliber staff √ Facilitates third-party reimbursements √ Creates a competitive advantage “We constantly strive to raise the bar within our organization, especially in the realm of care delivery. Achieving AAAHC Network Accreditation affirms our effort to provide our patients with the highest standards of care available.” - Jackie Hope, RN, BSHA, Director of Quality, CareATC, Inc. ADVANCESIN AAAHC ACCREDITATION 8
  • 9. Accredited Organizations Abound The universe of organizations AAAHC accredits is broad and varied. They include: • Ambulatory Surgery Centers • College and University Health Centers • Community Health Centers • Dental Group Practices • Dental Homes • Diagnostic Imaging Centers • Endoscopy Centers • Health Plan/Managed Care Organizations • Immediate/Urgent Care Centers • Indian Health Centers • International Organizations • Lithotripsy Centers • Medicaid Plans • Medical Group Practices • Medical Homes • Medicare Advantage Plans • Military Health Clinics • Multi-site Organizations • Occupational Health Clinics • Office-Based Surgery Centers • Retail Clinics • Specialty Services (e.g., radiology, dialysis and anesthesia) • Women’s Health Centers • Workplace On-site Clinics 9 More than 6,000organizations display the AAAHC Certificate of Accreditation. 148new organizations earned AAAHC accreditation in 2015.
  • 10. STANDARDSREFLECT CHANGING HEALTH CARE NEEDS The AAAHC Standards Committee is charged with monitoring Standards and making revisions to ensure they continue to be relevant, reflect the rapid changes in health care and comply with regulatory developments. This year’s report theme,“Embracing Change, Advancing Health Care,”truly captures the AAAHC team’s ongoing efforts to establish and update Standards to best address quality goals and patients’needs. What sets AAAHC apart from others in our field is the unique collaborative approach that incorporates input, insights and information from a broad-based team of association members, accredited organizations and the surveyors who work in health care daily as physicians, nurses, administrators and in other vital roles. A Distinct Perspective The beauty of this approach is that while AAAHC Standards are based on best practices, they are written in a way that enables compliance while still meeting the often unique needs of individual health care settings. In 2015, AAAHC embarked on a major initiative to develop“interpretative guidelines”to enhance the way we describe Standards to constituents. We began a comprehensive process to review the intent of each Standard. Our goal? Improve language where necessary and be more clear, concise and consistent. Special attention was given to Standards identified as new or particularly challenging for interpretation. This far-reaching endeavor continues in 2016 to further ensure Standards are communicated in the most effective and meaningful manner. Additional Significant 2015 Accomplishments Among other efforts conducted in 2015 to improve health care quality and foster patient safety: • Updated Standards for diagnostic imaging, laboratories and lithotripsy sites. • Focused significant attention, as in past years, on Standards that cover infection prevention and control. “When you visit an organization as a surveyor for AAAHC, the staff will really share everything. And it’s all for the good old fashioned reason that they want to improve quality. That’s inspiring.” - Dennis Schultz, MD, MSPH, AAAHC Surveyor 10
  • 11. 11 “My catch phrase to new surveyors is ‘what does the Standard say?’It reminds them they should educate themselves and the organizations they survey about the basis and intent of the Standards, engage with the organization’s staff to understand how they meet the Standards and share alternatives.” - Alsie Fitzgerald, RN, CASC, AAAHC Surveyor
  • 12. Traveling Miles for Smiles AAAHC surveyor Dr. Jeff Moses always loved his work as a craniomaxillofacial surgeon in the U.S., but sought a way to help children in other parts of the world without access to such care. Dr. Moses volunteered to treat children with facial deformities, usually cleft lips and palates. In 2005, Dr. Moses and his wife Maribel established the non-profit Smiles International Foundation which, for more than 10 years, has treated thousands of children in Costa Rica, Mexico, India, Ukraine and other countries. Treatment for cleft lips and palates requires three or four surgeries, so the teams of volunteers return to the same villages for several years. COMPASSIONAND CARING AROUND THE WORLD “Many babies born with this deformity are shunned or face ridicule until we complete treatments. We give them self-esteem, happiness and they are accepted as normal human beings. These children deserve that.” - Dr. Jeff Moses After Surgery, They Can See Again Mary Sibulsky has been a surveyor for AAAHC since 2007 and she taps her organizational skills as a manager of an ophthalmology center in Idaho to coordinate volunteer medical missions to Central America. The non-profit International Eye Institute that she and a team of doctors created provides adult and pediatric eye care and surgery to people in impoverished areas. Cataract extraction is a frequent procedure for helping those who are blind or nearly blind. “Many of these patients plan for months to attend our clinics – traveling by bus across borders or walking barefoot for days. We help change their lives and it’s a joy to provide this care.” - Mary Sibulsky 12 Medicine is people caring for people. For many of our folks, this dedication goes beyond a commitment to their own practice and accreditation work. They often devote their time to help others in need. Here are five stories of their inspiring work.
  • 13. 13 A Legacy of New Faces For Noreen DiPlacido, a long-time surveyor and RN, a semi-annual pilgrimage to Honduras with a group to provide dental and oral care to villagers that began in 1997 has now become a legacy. The group worked in remote areas with no electricity or running water and little in the way of equipment. Noreen, her husband Frank and their team then established New Faces for Honduras, an organization that sets up camps in small villages, treating thousands of in-need patients, many who had never seen a physician or health care worker. In partnership with other organizations, New Faces for Honduras now treats 30 to 35 major cases twice a year. “We also sponsor dental students financially and, at times, bring patients to the U.S. for treatment. It’s truly rewarding to know our valuable work continues.” - Noreen DiPlacido A Humbling Experience Dr. Michael Huey, an associate professor of family and preventive medicine at Emory University School of Medicine and a surveyor for AAAHC, took an unexpected long journey last summer. He strung together vacation time and work days to spend four weeks in Sierra Leone, one of the countries most affected by the unprecedented Ebola outbreak. As a member of the CDC Ebola West African response team, Dr. Huey toured health facilities, provided infection control recommendations and taught infection control classes for health care workers, ambulance drivers and crew and burial teams. “When my family immigrated to Chicago, I was 16 and did not speak a word of English. West Town was where I took my ‘first steps.’It is so satisfying to help patients when they can’t communicate their needs or concerns.” - Dorota Rakowiecki “It was profoundly humbling to witness the dedication and bravery of the health care workers who fought this terrible disease for more than a year. The world owes them a tremendous debt of gratitude.” - Dr. Michael Huey Helping the Old Neighborhood Dorota Rakowiecki’s volunteer work takes place much closer to home. The AAAHC Director of Ambulatory Accreditation Operations serves as a translator for Polish patients at the CommunityHealth clinic in Chicago’s West Town neighborhood. CommunityHealth delivers comprehensive, high-quality, patient-centered health care at no cost to low-income, uninsured adults in need of a medical home.
  • 14. THE JOURNEYTO BECOME CEO AT AAAHC For new AAAHC CEO Stephen A. Martin, Jr., PhD, MPH, it’s all about the journey. His deep-rooted philosophy sees excellence as a journey, not a destination. This applies to his focus and vision for AAAHC to make each client’s accreditation experience phenomenal through a collaborative learning approach. And it’s the AAAHC commitment to excellence that attracted the accomplished, experienced health care professional to the organization. The great appeal, said Dr. Martin, is that although by its very nature AAAHC works behind the scenes, the organization is at the forefront to help ensure people use top-quality health care organizations. “I like to draw a comparison to an airplane,”Dr. Martin said. “You trust the FAA as a third party organization to verify the plane’s safety. We do the same in health care by verifying best practices are followed, whether they involve infection control, the use of syringes, medical records, credentialing, proper training and many, many other variables.” Career Journey Multi-faceted Dr. Martin’s career journey encompasses public health, health care management and disease- based training and expertise as an epidemiologist, providing multi-faceted experiences ideal for helping lead AAAHC. Most recently, he was executive director for the Association for Community Health Improvement at the American Hospital Association (AHA). Dr. Martin also served as the chief program affairs officer for the Health Research & Educational Trust/AHA, the health commissioner and chief operating officer for Cook County (Illinois) Department of Public Health, and a senior executive with the Cook County Health & Hospitals System. “I have touched so many disciplines in my own career,”he said.“It gives me insight on how to best provide flexible accreditation approaches to organizations in a wide variety of health care settings.” 14
  • 15. 15 Experience Helps Respond to Industry Trends Such background is particularly beneficial given the changes occurring in health care today, including the continuum of care focus exemplified by the patient-centered medical home model, the constant consolidations and acquisitions and the growing influence of population health management. “Accreditation is the essence of population health management,” Dr. Martin said.“Accreditation focuses on the prevention of injuries and illness, and addresses ways to help eliminate the transmission of disease and infection. It should be positioned as a critical strategy that verifies policies and procedures that meet a series of metrics.” Another prevailing trend finds health care moving toward high-quality, low-cost settings, and one of the biggest challenges is to meet quality improvement goals with tighter budgets. “Providers are moving from fee-for-service to value-based contracts, and that’s where the work we do is critical,”he said.“We consider how we can empower our clients to meet their goals as well as industry goals within their budget constraints.” From the AAAHC perspective, as valued and essential as performance metrics may be, accreditation goes beyond those important data-driven analyses. “We offer not just a‘check the box’relationship, but collaborative, peer relationships different from others in our field,”said Dr. Martin.“AAAHC surveyors can say,‘Yes, I’m seeing the quality metric, but let’s determine how you can best use it.’Best practice sharing happens all the time, and it’s exciting to bring that to all of our clients.” As he’s addressed health care challenges over the years, Dr. Martin gains much inspiration from his father, Stephen A. Martin, Sr., who faced challenges of a different kind. Martin Sr. gained honors and accolades in 1966 by becoming the first African American to play any varsity sport (baseball) in the Southeastern Conference while at Tulane University, which played its games throughout the Deep South. “I learned how he handled this distinctive situation through his values, integrity and discipline,”Dr. Martin said.“That’s always been a great lesson for me when faced with challenges and changes. I can apply that today knowing that AAAHC is the right place and this is the right time for my new journey.”
  • 16. THE AAAHC INSTITUTE FOR QUALITY IMPROVEMENT A letter from Jan Kleinhesselink and Naomi Kuznets A roadmap to quality improvement. That phrase defines the essence of our mission at the AAAHC Institute for Quality Improvement. Since its founding in 1999 as a non-profit entity, the AAAHC Institute has been dedicated to providing resources and research to help ambulatory care facilities attain the highest levels of performance. We conveyed this commitment in 2015 when we changed the name of one of our most valuable tools, the AENEID Report, to AAAHC Quality Roadmap. This comprehensive analysis identifies patterns of compliance from the extensive AAAHC warehouse of accreditation survey data and offers guideposts on where and how organizations can improve and excel. For example, the AAAHC Quality Roadmap 2015 identified safe injection practices as a critical issue. The graphs on the opposite page highlight the report’s findings on this topic and others. Quality Roadmap data helps us prioritize and select subjects for another significant Institute initiative—our popular patient safety and disease management toolkits. These informative, reader-friendly brochures tackle key issues faced today by ambulatory health care organizations and offer guidance for best practices supported by evidence-based rationale. Our performance measurement and benchmarking studies offer another resource to help facilities attain quality goals. For the first time in 2015, we compiled data from more than 1,700 esophagogastroduodenoscopy (EGD) benchmarking studies to provide in-depth perspectives on best practices and procedures. In the past year, we also honored AAAHC-accredited organizations that conducted exemplary quality studies with our annual Bernard A. Kershner Innovations in Quality Improvement Award. The Institute team often takes leadership roles in professional groups to share insights and gain knowledge. For several years we have been involved with the Patient-Centered Primary Care Collaborative (PCPCC), an influential organization devoted to Patient-Centered Medical Homes (PCMH). This past summer, we served on the PCPCC Accreditation Work Group. We also continue to represent AAAHC and the Institute with national groups such as the ASC Quality Collaboration, National Quality Forum and Physician Consortium for Performance Improvement. These efforts to deliver innovative programs and meaningful research to meet our mission will continue at the highest of levels. Jan Kleinhesselink, RN, BSHM, CPHG Naomi Kuznets, PhD Chair, Board of Trustees Vice President and Senior Director AAAHC Institute for Quality Improvement AAAHC Institute for Quality Improvement 
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  • 17. 17 Compelling Results from AAAHC Quality Roadmap 2015 The Institute’s annual survey analysis, now called Quality Roadmap, revealed areas where providers are performing highly and areas that should be addressed for quality improvements. Among those with the overall highest deficiencies: Clinical Performance Measurement Reports In addition to the first Institute benchmarking report on EGD, other 2015 studies covered: • Cataract extraction with lens insertion • Colonoscopy • Knee arthroscopy with meniscectomy • Low back injection • Primary care • Shoulder arthroscopy • Surgical/procedural services Each report enables organizations to benchmark and learn best practices. New Toolkits Respond to Member Needs Patient safety toolkits address issues seen by surgery centers and primary care providers. • A toolkit for surgery providers,“Ambulatory Surgery and Obesity in Adults: Preventing Complications,”helps determine if surgery should be delayed or if a referral to a hospital should be made based on several medical conditions. • The“Disease Management Toolkit: Adult Depression and Primary Care”offers primary care providers best practice tools for screening and following up with patients for depression. Quality Improvement Award Winners The AAAHC Institute honored Seton Hall University Health Services, South Orange, New Jersey, with a 2015 Bernard A. Kershner Innovations in Quality Improvement Award in the primary care category for its comprehensive improvement study to more broadly implement alcohol screening methods and interventions in college health centers. Turk’s Head Surgery Center, West Chester, Pennsylvania, won a Kershner Award in the surgical/procedural category for implementing safeguards for patients when scopolamine patches are applied. Overall Highest Deficiencies For the third year in a row, AAAHC surveyors found notable deficiencies in credentialing, privileging and peer review policies. Safe injection practices were a leading deficiency discovered in 2015. More than 10% of ASCs, more than 9% of primary care organizations and more than 14% of office-based organizations reviewed had deficiencies in safe injection practices. Ensures that when opportunities for quality improvement are identified, the organization takes steps to demonstrate the implementation and success of corrective actions. Another area that many organizations may need to address is documentation that requires organizations to record allergies and untoward reactions to drugs and materials in a consistently defined location. Standard 7.I.C.2 Standard 5.I.C Standard 6.F Standard 2.II.D. 20% 14% 16% 13% Teresa Conklin, APN, Family Nurse Practitioner, at Seton Hall University Health Services, receives the primary care QI Kershner Award.
  • 18. ADVANCINGHEALTH CARE VIA EDUCATION, THOUGHT LEADERSHIP 18 We take seriously our role as health care quality leaders by commenting on trends and offering consultation for providers seeking quality improvement. Attendance Grows at AAAHC Webinars Our highly-attended, surveyor-led webinars provide ongoing education to accredited organizations. Among issues covered during the seven 2015 webinars were OSHA requirements, life safety code compliance, peer review, internal benchmarking and more. Proprietary Research Leads to Bylined Articles The data featured in the 2015 AAAHC Institute study on cataract extraction with lens insertion sparked interest from the Review of Ophthalmology, which published a three-page article on the topic authored by AAAHC surveyor Kris Kilgore, RN. Articles such as these by AAAHC members are published in leading professional journals throughout the year. Influencing International Audiences Illustrating the international presence of AAAHC and its Acreditas Global division, CEO Dr. Stephen A. Martin, Jr., addressed health care providers in Lima, Peru, attending the Primer Foro Profesional de Enfermería: Acreditacíon Internacional. Dr. Martin discussed how to use health care accreditation as a strategy for improving public health. Leading New Initiatives for Student Health Centers The AAAHC-accredited New York University Student Health Center received a grant in 2015 from the Agency for Healthcare Research and Quality to help other university student health centers design and perform quality improvement initiatives. The New York University Center invited AAAHC to serve on the program’s leadership committee and participate in a symposium on student health quality improvement. Staff from more than 150 universities attended the symposium, and AAAHC was the only accreditor in attendance.
  • 19. 19 HEALTHCARE CONSULTANTS INTERNATIONAL Consultation. Education. Resources. That’s the three-pronged program available from Healthcare Consultants International (HCI), the AAAHC for-profit subsidiary that helps health care organizations prepare for accreditation. Consultation. The HCI team of consultants and instructors helps organizations navigate the process of accreditation, licensure and certification (including Medicare). HCI also provides guidance in quality assurance, performance management, infection control, regulatory compliance and development of new facilities. In 2015, HCI expanded its services to health plans, including Federal Employee Health Benefit Plans. And it expanded its Policy & Procedure offerings with a customized set of templates for student health organizations. Education. The cornerstone of HCI educational initiatives is a webinar series that covers all 25 chapters in the AAAHC Accreditation Handbook for Ambulatory Health Care. For the 2015 handbook, 12 webinars featured presentations from a host of experts. Resources. More than 250 online tools and templates help organizations maintain accreditation, plus a complete set of Policy & Procedures Manuals for drafting language compliant with accreditation standards. Also available are regulatory updates and reviews of QI studies. HCI consulting services are separate and independent from the accreditation services of AAAHC. All accreditation decisions by AAAHC are made without regard to whether consulting services have been provided by HCI or any other organization. “HCI met our needs and exceeded our expectations. At the end of the day, we need to move fast in today’s health care environment and with HCI, we accomplished our goals.” - Scott Anderson, COO, Prairie Spine & Pain Institute
  • 20. COMMUNICATINGTO CONSTITUENTS We are an organization built on personal relationships, and as in any good relationship, communication is vital. We use a number of channels, digital and print, paid and earned, to speak with our stakeholders about the benefits of accreditation and the work we are doing to improve health care quality. 20
  • 21. 21 Direct Outreach We use Facebook, LinkedIn and Twitter to engage with organizations, employees and industry colleagues. We also issue a Surveyor News & Education (SNE) newsletter directly to surveyors to share news and thought leadership articles. Placing Articles in Prominent Trade Media Modern Healthcare, Becker’s ASC Review, Medical Economics, OR Today and Review of Ophthalmology are just a small sample of the outlets that featured editorial coverage of AAAHC, including multiple bylined thought leadership articles by AAAHC executives and board members. AAAHC and its sister divisions appeared in more than 1,100 articles in 2015. Creating Brochures for Promising Markets We build marketing materials that speak directly to key audiences about our tailored offerings, such as those for employer-based clinics, student health clinics, health plans, urgent care centers and our network accreditation program. Collaborating with Stakeholders for New Ad Campaign In developing our latest advertising campaign, we convened groups of surgery center and primary care professionals to determine messages and images that would resonate with them. The ads are running in targeted online and print medical trade publications. Improving health care quality through accreditation Contact us to learn more 847-853-6060 • info@aaahc.org • www.aaahc.org A A A H C A C C R E D I T A T I O N{ } It’s an opportunity to see your organization from the outside. When AAAHC surveyors survey your organization, it’s not a checklist kind of visit. It’s your fellow professionals - physicians, nurses, administrators - coming to help you be the best you can be. • We are the leader in ambulatory accreditation. • Our Standards are nationally-recognized. • Our surveys are consultative not just a checklist.
  • 22. AAAHC 2015/2016 Board of Directors Edward Bentley, MD, 2006 R. Bruce Cameron, MD, FACP, 2015 Frank J. Chapman, MBA, 2005 Ira Cheifetz, DMD, 2013 W. Patrick Davey, MD, MBA, FACP, 2003 Jan Davidson, MSN, RN, CPHRM, 2011 Mark DeFrancesco, MD, MBA, 2000 Meena Desai, MD, 2009 Robin J. Elwood, MD, FAAP, 2015 Ann B. Geier, RN, MS, CNOR, CASC, 2014 Richard D. Gentile, MD, MBA, 2006 Dave Hamel, DDS, 2015 Joy Himmel, Psy.D., PMHCNS-BC, LPC, 2015 George Hruza, MD, 2015 Sandra Jones, CASC, CHCQM, LHRM, MBS, MSM, 2012 John P. Keats, MD, CPE, 2014 Lawrence S. Kim, MD, 2004 Ross Levy, MD, 2012 W. Elwyn Lyles, MD, 2011 Mark Mandell-Brown, MD, 2013 S. Teri McGillis, MD, 2006 Timothy Peterson, MD, 2009 Beverly Philip, MD, 2000 Kenneth M. Sadler, DDS, MPA, FACD, FICD, 2005 David Shapiro, MD, 2013 James E. Schall, DDS, 2011 Dennis Schultz. MD, 1994-2003, 2009 Edwin Slade, DMD, JD, 2004 Arnaldo Valedon, MD, 2010 Mary Ann Vann, MD, 2008 Christopher J. Vesy, MD, 2011 Datesindicatebeginningyearofservice Frank J. Chapman, MBA, Chair Meena Desai, MD, Vice Chair Kenneth M. Sadler, DDS, MPA, FACD, Treasurer Arnaldo Valedon, MD, Secretary W. Patrick Davey, MD, MBA, FACP, Immediate Past Board Chair 2015/2016 Officers AAAHC Association Members ASCA Foundation American Academy of Cosmetic Surgery (AACS) American Academy of Dental Group Practice (AADGP) American Academy of Dermatology (AAD) American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) American Association of Oral and Maxillofacial Surgeons (AAOMS) American College of Gastroenterology (ACG) American College Health Association (ACHA) American College of Mohs Surgery (ACMS) American Congress of Obstetricians and Gynecologists (ACOG) American Dental Association (ADA) American Gastroenterological Association (AGA) American Society of Anesthesiologists (ASA) American Society for Dermatologic Surgery Association (ASDSA) American Society for Gastrointestinal Endoscopy (ASGE) Association of periOperative Registered Nurses (AORN) Society of Ambulatory Anesthesia (SAMBA) 22 Leadership and Association Members
  • 23. AAAHC Executive Staff Stephen A. Martin, Jr., PhD, MPH President and CEO Breian Meakens, MPA, MBA Chief Operation Officer Michael Janniere, JD SeniorVice President and Chief People Officer SergioTumang Chief Financial Officer andVice President, Administration Ray Grundman, MSN, MPA, FNP-BC, CASC Chief Business Development Officer Tess Poland Vice President, Ambulatory Operations Naomi Kuznets, PhD Vice President and Senior Director, AAAHC Institute for Quality Improvement Meg Gravesmill, MBA, MPA Vice President, Hospital Operations, AAHHS Kristine Mighion, MD, MBA Managing Director and CEO, Healthcare Consultants International AAAHC Financial Summary 23
  • 24. Like us on Facebook at facebook.com/AccreditationAssn Find us on LinkedIn at linkedin.com/company/2430500 Follow us on Twitter at @AAAHC_QUALITY Watch us on YouTube at youtube.com/user/AAAHC60077/videos Accreditation Association for Ambulatory Health Care aaahc.org 5250 Old Orchard Road, Suite 200 Skokie, IL 60077 Tel: 847.853.6060 Fax: 847.853.9028 info@aaahc.org AAAHC Institute for Quality Improvement aaahc.org/institute 5250 Old Orchard Road, Suite 250 Skokie, IL 60077 Tel: 847.853.6060 Fax: 847.853.6118 info@aaahc.org Accreditation Association for Hospitals/Health Systems aahhs.org 142 E. Ontario St., 10th floor Chicago, IL 60611 Tel: 312.202.8062 Fax: 312.202.8362 info@aahs.org Acreditas Global acreditasglobal.org 5250 Old Orchard Road, Suite 200 Skokie, IL 60077 Tel: 847.853.6060 Fax: 847.853.9028 info@aaahc.org Healthcare Consultants International hciconsultants.com 5250 Old Orchard Road, Suite 360 Skokie, IL 60077 Tel: 888.982.6060 Fax: 847.853.9028 info@hciconsultants.com