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

Volume 4 | Issue 3 | Summer 2017

Exterior of TCC's primary facility, Chief Andrew Isaac Health Center, in Fairbanks, Alaska Spotlight on: Tanana Chiefs Conference For over 10,000 years, an indigenous, nomadic people have hunted, trapped, and fished the 45 million acres—roughly 31% of Alaska—that the Tanana Chiefs Conference (TCC) now serves. The story of these tribes attests to a spirit of self-determination, perseverance, and commitment to community in a richly resourced, but harsh and isolated environment.

BEGINNINGS that, for the tribes, had been traditionally from the health center in Fairbanks, to recognized tribes. Today TCC employs In 1741, the Russian Empire conquered open and free. 24 sub-regional clinics serving 16,000 950 people with an average operating a small area of Alaska intending and American Indians. budget of $155 million. FORMATION OF TCC to colonize it. More than a century TCC also serves 700 non-Native veterans In the latter half of the twentieth During the 2012 construction of the later those efforts were abandoned through an agreement with the U.S. century, Alaska became a state (1959), new CAIHC, cultural items and earth and Russia sold its territorial claim Veterans Administration. The governing and in 1962, at a meeting of 32 from the villages served by the facility to the United States. While no local body for the organization’s health surrounding villages in Tanana, Dena’ were brought and incorporated into Native tribes or chiefs were consulted services is the TCC Regional Health Nena’ Henash (dba Tanana Chiefs the building and its grounds. This during the negotiations, the 1867 sales Board. This group consists of eight tribal Conference) was incorporated. goes to the heart of the organization’s agreement included language requiring members from within the TCC region. inclusivity: everyone is welcome; the U.S. to settle land claims of the A decade later, TCC successfully bid to The larger organization, which provides everyone is invested; everyone “owns” indigenous people. receive grants from the state of Alaska many other social and community the facility. to provide health care, social services, Once the U.S. took ownership of the development services, is made up of and public safety services to all residents land, the area began to see an influx 42 members representing 37 federally continued on page 6 of metropolitan Fairbanks and smaller of non-Native settlers, in part, due to villages. In the mid- Interior of the Chief Andrew Isaac Health Center with cultural items from surrounding villages served by TCC a local gold strike. Tanana, meaning 1980s, TCC began clinical operations “the place where two rivers meet,” was by assuming management of the Alaska an important point of contact between Native Health Center in Fairbanks, Native tribes and settlers, a crossing of renaming it Chief Andrew Isaac Health cultures that also brought conflict. Land Center (CAIHC) after a traditional tribal disputes erupted between settlers and leader of the region. Natives over the deeding and ownership of hills, streambeds, and rivers, land Today TCC operates 25 facilities, ranging During the 2012 construction of the new CAIHC, cultural items and earth from the villages served by the facility were brought and incorporated into the building and its grounds. This goes to the heart of the organization’s inclusive approach to healthcare: everyone is welcome; everyone is invested; everyone “owns” the facility.

In Memoriam: Dr. John E. Burke New look for 2018 Standards

AAAHC is saddened to announce the passing of former AAAHC president and CEO, The next edition of the Accreditation For example, Chapter 1, Patient Dr. John E. Burke. Handbook for Ambulatory Health Care— Rights and Responsibilities, intends Dr. Burke retired in June 2015, after 18 years with AAAHC and, over the course the version of our handbook that is to emphasize patient-centeredness as of his career, more than 40 years’ experience in healthcare. On the eve of his used by all organizations except ASCs essential to an accreditable organization. that participate in the Medicare Deemed The current handbook reads: continued on page 2 Status program—will present the AAAHC 1.A Patients are treated with respect, Standards with a different look. While consideration, and dignity. there are only minimal changes to the The next four Standards, 1.B-E, address content of the Standards, they have all personal privacy, provider-patient Standard Bearer Surveyor spotlight been redrafted to reflect a big picture communication, patient engagement view followed by a set of descriptors Standard 5.I.C is the infamous “quality “Understanding the rigors that an and shared decision-making. For 2018, or “elements of compliance” that reflect improvement study Standard.” Its 10 accredited center has had to meet Standard 1.A has not changed, but specific, yes-no decision points. These elements are the components of an or exceed in order to achieve that Standards 1.B, C, D, and E will become elements of compliance should provide ongoing cycle of improvement. accreditation makes me feel more the “elements of compliance” that serve for a closer alignment between an comfortable as a health care consumer to describe what we intend by “respect, when seeking care for myself or others.” organization's self-assessment and that of an on-site surveyor. Page 2 Page 7 continued on page 3

IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION SUMMER 2017 | TRIANGLE TIMES ›› 1 Standard Bearer: 5.I.C.10 Communication of QI results

Standard 5.I.C is the infamous and build investment in change is one documentation. The chart below shows For data-driven results “quality improvement intent of 5.I.C.10. A second is to how the PDSA model can crosswalk Registration is open for July-December study Standard.” Its 10 build a culture of continuous with these elements. However, PDSA 2017 benchmarking studies. Review elements reflect the improvement by formalizing the starts with setting an objective or goal topics and register for currently available components of a process. Once a corrective action and AAAHC recommends that the search studies at www.aaahc.org/institute/ completed quality has been taken and proven for a meaningful QI study begin with a Benchmarking. improvement successful, its sustainability review of data that your organization is For developing a QI program/ cycle that depends on telling the already collecting and an evaluation of understanding the QI process demonstrate story of what happened, your performance against benchmarks— Illuminating Quality Improvement is to your AAAHC why it happened, and how the your own (internal) or those of like a workbook used at our Achieving surveyor that your new, improved state will be organizations (external). If you find that Accreditation seminars that is now organization has an active, maintained. you are not meeting the benchmark, then available as a self-study tool. It’s available ongoing, data-driven, MEETING THE STANDARD you have identified a study opportunity. for purchase at peer-based program of The ten elements of This is the point at which the PDSA cycle www.aaahc.org/publications. quality improvement. of activity begins. Standard 5.I.C create a For recognizing excellence While the elements are not steps to structure for quality improvement. ADDITIONAL QI RESOURCES Nominations are open for the Bernies! be completed in a particular order, Other models are equally valid and easily For benchmarking The Bernard A. Kershner Innovations in depending on how frequently (and by align with the AAAHC structure. For Each year, we release AAAHC Quality Quality Improvement Award is awarded what means) your organization reports example, many organizations like the Roadmap, an annual summary of for QI studies in surgical/procedural on quality activity, 5.I.C.10 may represent PDSA (Plan, Do, Study, Act) model for its high-frequency deficiencies from all and primary care categories. Six finalists a culmination before an improvement emphasis on QI as a cycle. surveys performed under the prior year’s (three for each type of setting) are cycle begins again. For AAAHC, a quality improvement study Standards. You can use this publication announced in November and present THE STANDARD is documentation that an improvement in conjunction with your survey report to their studies at Achieving Accreditation 5.I.C. The organization demonstrates that opportunity was identified, a corrective see how your organization is performing in March when winners are announced. ongoing improvement is occurring action undertaken, and a sustainable on individual Standards compared to For more details, visit peers. Free digital copies of the 2016 by conducting quality improvement improvement the result. The ten http://www.aaahc.org/institute/ edition of AAAHC Quality Roadmap can studies when the data collection elements of Standard 5.I.C create a QI-awards/ s processes described in Standard framework and describe the components be found at www.aaahc.org/institute/ 5. I. B indicate that improvement that should be included in your Quality-Roadmap. is or may be warranted. Written descriptions of QI studies document Standard 5.I.C.1 each of the following elements, as P PLAN A statement of the purpose ... applicable: ■ Objective Standard 5.I.C.2 10. Communication of the findings Identification of the measurable performance goal ... ■ Prediction of the quality improvement Standard 5.I.C.3 ■ Data Collection Plan activities to the governing body and A description of the data that will be collected…to determine current performance. throughout the organization, as Standard 5.I.C.4 appropriate, and incorporation D DO Evidence of the data collection. of such findings into the ■ Collect the data Standard 5.I.C.5 organization’s educational Data analysis… ■ Begin data analysis activities (“closing the QI loop”). Standard 5.I.C.5 (continued) INTENT OF THE STANDARD S STUDY …findings about the frequency, severity, and source(s) of the problem(s). In order to integrate quality improvement Standard 5.I.C.6 throughout an organization, it’s important ■ Complete the data analysis A comparison of the organization’s current performance against the performance goal. to communicate priorities and celebrate ■ Compare data to prediction success. Other elements of Standard ■ Summarize what you learned 5.I.C require data collection and analysis Standard 5.I.C.7 to drive goal-setting. When a target is A ACT Implementation of corrective action... missed or analysis shows a declining ■ Plan the next cycle Standard 5.I.C.8 trend in performance, widespread Re-measurement... ■ Determine if the change can knowledge of the opportunity for be implemented Standard 5.I.C.9 improvement can lead to innovative … additional corrective action… solutions. Sharing issues that have Standard 5.I.C.10 been identified in order to prioritize Communication of the findings…

In Memoriam: Dr. John E. Burke, continued from page 1 retirement, Dr. Burke reflected on his tenure at AAAHC, saying, “It has been an program based on on-site incredible privilege to serve an organization with so many talented people who are review in 2009; establishing all committed to the same mission.” of AAAHC International (now As an undergraduate, Dr. Burke double majored in communications and political Acreditas Global) in 2010. science. While studying for a doctorate, he took a job at a local television station. Employees who worked with However, his focus shifted from broadcast communications when he was appointed him over the years remember head of the Department of Medical Communications within the School of Allied Dr. Burke as a mentor Medical Professionals at The Ohio State University. As he observed in a 2014 who encouraged them by interview, “from that point to this, I’ve worked at the intersection of communications emphasizing their strengths and health care.” and focusing on the positive. Dr. Burke earned his MFA from Ohio University in 1966 and his PhD from The Beyond communications and Ohio State University in 1971. He later worked in the College of Associated healthcare, Dr. Burke was Health Professions at the University of Illinois at Chicago as an associate dean and a passionate collector. In professor. Prior to joining AAAHC in 1997, Dr. Burke managed programs in medical 2015, he published a memoir, communications and scientific relations for Abbott Laboratories in Abbott Park, Never Enough: Confessions Illinois. of a Capricious Collector, a Under Dr. Burke’s leadership, AAAHC grew significantly and experienced personal and knowledgeable tremendous financial success. Landmark achievements during his tenure include: account of his growth as a increasing the number of AAAHC-accredited organizations from approximately 600 collector of netsukes, Persian to 6,000; expanding skilled support staff from eight full-time employees to more carpets, walking sticks, and than 65; founding the AAAHC Institute for Quality Improvement in 1999 to provide antique watches. opportunities for ambulatory health care organizations to benefit from performance Dr. Burke is survived by his wife, Mary Kay, their three children, Elizabeth, John, and measurement and benchmarking; launching the first Medical Home accreditation CC, and many loving grandchildren and great-grandchildren. s

2 ›› TRIANGLE TIMES | SUMMER 2017 IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION Welcome to our newly accredited organizations Congratulations to the 116 new organizations accredited by AAAHC between January 1 and June 30, 2017.

ALASKA Maria E. Mora, MD, PA ASC Development Company, LLC - OHIO Eric Nordstrom, DDS, MD, Inc. Mariano D. Cibran, MD, Corp Waldorf Anderson Endoscopy Center, LLC Surgery Center of Kenai, LLC Miami Surgery Center, LLC ASC Development Company, LLC - White New Horizons Surgery Center Marsh Nirmala, Inc. Surgery Center at Corporate Way, LLC ARIZONA Orthopedic Surgery Center of Palm Beach MASSACHUSETTS AKDHC Surgery Center, LLC OREGON County, LLC Mashpee Service Unit Central Arizona GI and Liver Institute, LLC Dental Service, LLC St. Anthony’s Physician Surgery Center West Suburban Eye Surgery Center, LLC Heart and Vascular Surgical Center, LLC Trinity Surgery Center, LLC PENNSYLVANIA Pima Heart ASC, LLC MICHIGAN Volusia Orthopaedic Trauma Call Associates, Allegheny Health Network Surgery Center - LLC DDS-Tapestry, LLC CALIFORNIA Bethel Park, LLC Executive Ambulatory Surgery Center, LLC Aditya Verma MD, Inc. GEORGIA Ridley Crossings Surgical Center Flint Region ASC Affinity Surgery Center, Inc. Beacon of Hope West Shore Pain and Spine Institute, LLC Genesys Surgery Center, LLC Bloss Memorial Healthcare District Caring Solutions of Central Georgia, Inc. (dba Great Lakes Surgery Center, LLC SOUTH CAROLINA Buena Vista Surgery Center CORE Healthcare for Women of Central Georgia) Michigan Cosmetic, PC Carolinas Ambulatory Surgery, Inc. Cascade Health Partners, LLC Coosa Procedure Center Lucas Facial Plastic & Cosmetic Surgery College Area Pregnancy Services MINNESOTA Center Georgia Skin Cancer Surgery Center, LLC Concierge Surgical Center, LLC Twin Cities Surgery Center Upstate Affiliate Organization Midtown Surgery Center Native American Health Center, Inc. NASA Surgery Center MISSOURI TENNESSEE Newport Institute of Minimally Invasive Surgery Resurgens East Surgery Center, LLC Government Employees Health Association, Surgicare of Southern Hills, Inc. West Paces Surgery Center, LLC Inc. (health plan) OC Multi Specialty Surgery Center, Inc. Orchard Creek Surgery Center ILLINOIS MONTANA Bluebonnet Surgery Pavilion, LLC Pacific Ambulatory Surgery Center, LLC Advocate Condell Ambulatory Surgery Center, New Hope Clinic Crenshaw Ambulatory Surgery Center, LLC Pacific Coast Surgical Center, LP LLC NEVADA RYMD Surgery Center, LLC Palo Alto Medical Foundation for Health Care Union Health Service, Inc. (health plan) Saratoga Surgical Center, LLC Research Leo J Capobianco, DO, Ltd. INDIANA West Gray Center for Special Surgery Southern California Head & Neck Surgery NEW JERSEY Center Goshen Health Surgery Center, LLC Woodridge Surgical Center, LLC Hamilton Surgical Services, PA Sutter Bay Medical Foundation Interventional Pain Management, LLC Health Plus Surgery Center, LLC VIRGINIA Total Health Surgery Center, LLC LPC Surgery Center, LLC Retina Consultants Surgery Center Independent Associates, PC Universal Care Surgery Center, LLC KANSAS The Center for Advanced Oral & Facial Radiologic Associates of Fredericksburg COLORADO Vargas Face and Skin Center Surgery, LLC Reston Endoscopy Center Audubon Ambulatory Surgery Center, LLC KENTUCKY NEW YORK WASHINGTON Northglenn Endoscopy Center, LLC Dental SurgiCenter of Louisville, Inc. CNY Facial Surgery Group, PC Lewis County Community Health Services Plan de Salud del Valle, Inc. East 56th Street Medical, PLLC MARYLAND WISCONSIN CONNECTICUT Elan B. Singer, MD, PC ASC Development Company, LLC – BJOSC at Plover, LLC HHC Hartford Surgery Center, LLC Long Island Digestive Endoscopy Center, Bowie LLC Summer Street ASC, LLC GUAM ASC Development Company, LLC - New Look New Life Cosmetic Surgical Arts Germantown Calvo’s SelectCare underwritten by Tokio DISTRICT OF COLUMBIA PLLC Marine Pacific Insurance (health plan) ASC Development Company, LLC - Surgery of Tomorrow, LLC National Postal Mail Handlers Union (health Glen Burnie plan) PANAMA ASC Development Company, LLC - NORTH CAROLINA PCABP - AJAC Administered by AXA FLORIDA Pikesville C Healthcare Associates, Inc. Assistance (health plan) Advanced Center for Surgery, LLC ASC Development Company, LLC - Holly Springs Surgery Center, LLC Rockville VIRGIN ISLANDS Atlantic CardioNet, LLC Mountain Area Health Education Center, Inc. ASC Development Company, LLC - Paradise Surgical, LLC Belkys Bravo, MD, PA Silver Spring Rockford Digestive Health Endoscopy Center, Children’s Health Alliance, LLC PA

New look for 2018 Standards, continued from page 1

consideration, and dignity.” more confidence within an organization Similarly, there are many current about the outcome of an accreditation Standards that include multiple decision or re-accreditation application. We points. When this is the case, it can believe that organizations will be be challenging to decide whether the better prepared and will appreciate the presence of some of the parts constitutes increased transparency of how they are “substantial” or “partial” compliance. being evaluated. For 2018, these Standards have been Educational programs will use the edited into separate elements that can new Standards as their reference be evaluated more directly as yes (the beginning with the September Achieving element is present), no (the element is Accreditation program. They will not present), or NA (the element is not become effective for surveys beginning applicable to this organization). on or after March 1, 2018. Information Following each Standard and its about how to access the new handbook elements of compliance, the new will be provided by email by October 1. handbook will show a chart that defines, Although ASCs in the Medicare Deemed based on the number of “yes” answers, Status program will not see the same whether the Standard can be rated Fully, changes in the handbook they use— Substantially, Partially, Minimally, or though CMS Conditions for Coverage Non-compliant. have always been rated as Compliant or This rating methodology has been in Non-compliant—we do expect to release use since 2012 for our health plan a revised version of the Accreditation accreditation programs where it has Handbook for Medicare Deemed Status proven to increase clarity of intent. We Surveys later this year. s believe our primary care and surgical customers will appreciate this approach as well. ELIMINATING SURPRISES By providing more specificity around what AAAHC surveyors will be looking for, there should be few, if any, surprises at the time of an on-site survey, and

IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION SUMMER 2017 | TRIANGLE TIMES ›› 3 Calendar

= education = outreach

July 2017 Dates Connection published

S M T W Th F Sa Triangle Times published

Registration open for July-Dec. 2017 benchmarking studies 1 http://www.aaahc.org/en/institute/ Benchmarking/

2 3 4 5 6 7 8 10 Applications open for the Bernard A. Kershner Innovations in Quality Improvement Award (“The Bernies”) 9 10 11 12 13 14 15 www.aaahc.org/institute/QI- awards/

16 17 18 19 20 21 22

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30 31

August 2017 Dates 6-9 National Conference of State Legislators (NCSL) Boston, MA S M T W Th F Sa (exhibit)

11-13 American Society for 1 2 3 4 5 Gastrointestinal Endoscopy (ASGE) Hollywood, CA (exhibit)

23 Early Bird registration deadline for 6 7 8 9 10 11 12 September Achieving Accreditation 27-29 National Association of Community Health Centers (NACHC) 13 14 15 16 17 18 19 San Diego, CA (exhibit & speaker)

20 21 22 23 24 25 26

27 28 29 30 31

September 2017 Dates Connection published

S M T W Th F Sa 6-8 California Ambulatory Surgery Association (CASA) Indian Wells, CA (exhibit & speaker)

1 2 22 Applications close for the Bernies

3 4 5 6 7 8 9 22-23 Achieving Accreditation (Washington, DC)

30 Benchmarking study reports from 10 11 12 13 14 15 16 January-June 2017 available for purchase

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4 ›› TRIANGLE TIMES | SUMMER 2017 IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION Legislative updates

CMS PROPOSES NEW RULE TO MAKE this concern by engaging a panel of Florida’s Agency for Health Care accreditation organization’ means a SURVEY REPORTS PUBLIC accreditation organizations, experts, and Administration (AHCA), the chief health private nonprofit entity that sets national AAAHC has written a response to other stakeholders. policy and planning entity for the state, utilization review and internal appeal proposed rule changes to 42 CFR §488.5 For the complete response, please go to: reported between June 2015 and June standards and conducts review of requiring accreditation organizations http://bit.ly/2t10Y3c 2016, freestanding ASC averaged charges insurers, agents, or independent review (AOs) to post final accreditation ranging from $3,034 to $7,902 and entities for the purpose of accreditation FLORIDA survey reports and acceptable plans hospital-based ASC/outpatient facilities or certification. Nationally recognized Florida passes 24-Hour stays for ASCs of correction (PoCs) for organizations averaged charges ranging from $8,669 to accreditation organizations shall include participating in the Medicare deemed In March, the Florida State Senate passed $28,624. Based on this data, the numbers the Accreditation Association for status program on the public-facing Bill 145 which extends the amount appear to support decreased cost. Ambulatory Health Care (AAAHC).” of time a patient can stay in an ASC. website maintained by the AO. ASCs in Florida accredited by AAAHC Traditionally, an ASC is defined as a While AAAHC supports CMS in its that begin offering extended hours and “AAAHC believes there facility, not affiliated with a hospital, initiative to assist consumer decision- 24-hour stay options will be responsible that provides elective surgical care—the may be more effective making through transparency, we believe for Standards in Adjunct Chapter 20, caveat being that patients must be treated the proposal will not support that goal. "Overnight Care and Services." ways to address this and discharged on the same calendar The significant variation in survey report day. Bill 145 extends an ASC stay for KENTUCKY format across the industry (thereby concern.” patients to 24 hours. AAAHC recognized for Health Plan making researching and comparing AOs accreditation in Kentucky Tom Tassone, AAAHC Director of Health more difficult) will cause confusion According to proponents of the bill, Plans, and AAAHC attorney, Ann Carrera, In March, Kentucky Governor, Matt among consumers who may not have allowing ASCs to keep patients overnight have been leaders in presenting AAAHC Bevin, signed legislation which named knowledge and understanding of will help defray costs of procedures. In as a resource to state legislators dealing AAAHC as a recognized health plan accreditation or the relationship between the current environment, if a patient is with the complexity of health care issues. unable to be discharged by closing time, accreditation organization in the state. accreditation and the Medicare Deemed s Status program. AAAHC believes there that patient must be transported to a The relevant section of the legislation may be more effective ways to address hospital, raising the overall cost. reads, “‘Nationally recognized

Meet the AAAHC staff

found her way to AAAHC. “I trained for When Tammy is not calming jittery- three months, and then had my three- sounding callers or fielding questions month probationary period. After that about the application process, she I was hired as a full-time employee of has a range of interests like reading, AAAHC.” cooking, and photography. She is one of the founding members of AAAHC “Our customers have Book Club which meets quarterly and is entering its second year of discussing a choice of accrediting member-selected books. She is also bodies, and when a rumored to make a knock-out Shrimp Veracruzana [see recipe below]. The key, potential client calls, I she hints, is using all fresh ingredients. feel we have to quickly Another hobby is bicycling. For the past demonstrate the 12 years, Tammy has participated in the Apple Cider Century Ride in Three Oaks, TAMMY FAGAN benefits of choosing Michigan. It is an early fall, one-day APPLICATION COORDINATOR AAAHC. One of the most event spanning 100 miles, that takes riders through small towns and rural For Tammy Fagan, one of the most important parts of my job backroads. “It is a lovely time of the year important components of her role in is the advocacy role, one and this is not a race. We ride at our Accreditation Services is the personal leisure without any pressure to complete interaction with organizations. Many that says, ‘I am someone the entire 100 miles. While we ride, we times, she observes, the caller on the you can talk to. I’m on stop along the way. I always bring my on providing customer service other end of the phone is unfamiliar camera and take pictures of the scenery to organizations preparing for an with the accreditation process. “Maybe your side.’” and the people. It’s a time to enjoy the accreditation survey. “I know I am the the person is a new hire who was just weather and spend the day with close initial contact and help put a human face handed this responsibility. They need For Tammy, the importance of friends.” on the process.” s some assurance,” she says, “that AAAHC accreditation from a patient’s perspective At AAAHC, Tammy has no time for and I will be with them every step of comes down to, “am I going to such a leisurely pace. Her day, from the way.” be safe?” From an organization’s start to finish, is focused In 2014 Tammy came to AAAHC on a perspective, she views AAAHC as temporary assignment and transitioned providing guidance to her current position as Application and consultation to Coordinator serving East Coast ASCs six help them build their months later. business by offering the “Our customers have a choice of highest level of patient Tammy’s Shrimp Veracruzana accrediting bodies,” she says, “and when care. “The Standards PREPARATION provide a framework,” INGREDIENTS Heat oil in a large nonstick skillet over medium heat. a potential client calls, I feel we have 2 teaspoons olive oil observes Tammy, “the Add bay leaf and cook for 1 minute. Add onion, jalapenos, to quickly demonstrate the benefits 1 bay leaf information that facilities and garlic, cook, stirring until softened, about 3 minutes. of choosing AAAHC. One of the most 1 medium onion, halved and need to provide quality Stir in shrimp, cover and cook until pink, just cooked important parts of my job is the advocacy thinly sliced through, 3-4 minutes. Stir in tomatoes and olives. Bring care and operate role, one that says, ‘I am someone you 2 jalapeno peppers, seeded and to a simmer, reduce heat to low, replace cover and cook effectively. They also finely chopped can talk to. I’m on your side.’” until the tomatoes are almost broken down, 2-3 minutes move organizations 4 cloves of garlic, minced Coming to AAAHC was a “huge more. Remove bay leaf. Serve with lime wedges and from being reactive to 1 pound peeled and deveined sliced avocado. transition” for Tammy. For seven years, proactive. Rather than shrimp (Larger shrimp 16-20 she worked as a frame shop manager for per pound) *** In the winter months my family likes it served over rice. addressing a problem a popular hobby and craft store chain. 4 Roma tomatoes, diced As a variation, skinless, boneless chicken breasts can after it has occurred, **** In 2009 she went back to school, and ¼ cup thinly sliced pitted be used instead of the shrimp. Cooking time for the the Standards address green olives in 2011 she graduated with a degree sliced chicken breast is 5-7 minutes, until no longer pitfalls and allow for lime cut into wedges in Business Administration. To satisfy 1 pink and cooked through. troubleshooting, if needed, a “yearning” (as she describes it) for 1 large avocado, cut into slices to head off any potential advocacy and law, she completed a issues for the future.” paralegal degree in 2013. Eventually, she

IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION SUMMER 2017 | TRIANGLE TIMES ›› 5 Spotlight on: Tanana Chiefs Conference, continued from page 1

Last year, the health system supported environmental obstacles we deal with.” Geographic area 147,000 patient visits, 129,000 of them of Alaska served GEOGRAPHIC CHALLENGE TO CARE at CAIHC. The approach to health and by TCC (in blue) Providing healthcare to communities wellness is holistic. The center offers across a vast geographic area presents a full range of services which include: unique difficulties, especially when diabetes care, immunizations, obstetric some regions are extremely remote. care, orthopaedics, pediatrics, radiology, Access and geographic isolation make women’s health, dental, optometry, emergency care difficult. To physical therapy, acupuncture, and address these problems, TCC has internal medicine, among others. As a the Community Health Aide/ community resource, the facility also Practitioners Program (CHAP), a includes a fitness center offering a range program unique to of classes, such as yoga and Zumba. Alaska. There are AAAHC AND TCC approximately 550 Three facilities beneath the umbrella of aides/practitioners Dena’ Nena’ Henash—which translates in Alaska, who as “Our Land Speaks”—were surveyed serve as the frontline in 2016: the Chief Andrew Isaac Health healthcare providers in over 170 Center, and two sub-regional clinics. rural Alaska villages. They are trained as providers within a Ms. Amber Jordan, who served as defined scope of practice “The surveyors were and work within the guidelines of the Alaska complimentary of our Community Health Aide staff and made them Practitioner Manual under challenging circumstances the license of a physician. The concept in their facilities. As part of the comfortable. There is that community health aides, who preparation process, we reviewed was no hand slapping; are employed by tribal healthcare and added significant content to the organizations, can assess, diagnose, treat manual to better serve and guide it was not just people and refer their community members to our rural clinic staff. Documentation coming in and checking the medical care they need, in close provides consistency in care and clinical collaboration with the medical staff at approach not only within our main boxes. They were there the tribal health organizations in facility, CAIHC, but across the various larger hub-communities. outlying clinics. Accreditation helps our to really help us improve, Based on her facilities by providing a roadmap for One AAAHC surveyor experiences preparing the where necessary, but improvement.” observed, “Their geographic organization for past surveys and were quick to point out coverage area is 31% of the state of accompanying the survey team during She adds, “the surveyors were Alaska. They are serving patients who the 2016 site visit, Ms. Jordan feels the complimentary of our staff and made the positive as well.” live on interior rivers with access accreditation process strengthens the them comfortable. There was no hand by water only—no roads, trains or organization and improves the care it slapping; it was not just people coming TCC Health Services’ quality director landing strips (though in some cases, provides. The benefits of accreditation in and checking boxes. They were at the time, was onsite for the CAIHC you can land small planes). There is are two-fold, according to Ms. Jordan: 1) there to really help us improve, where reaccreditation survey and considers no electricity or running water in the a focus on improving the quality of care necessary, but were quick to point out it a very positive experience. “We homes. The organization’s focus on the and 2) Standards which provide a solid the positive as well.” appreciated the fact that one of patient extends far beyond the clinic administrative infrastructure to support American Indian and Alaska Native the surveyors had worked in tribal walls and it does an excellent job of high-quality clinical operations. tribes recognize and honor the heritage healthcare and also had participated providing care where, when, and how “The process of preparing for a survey passed down to them by their ancestors. in Alaska tribal surveys. Sometimes the patients want and need services.” helps us maintain consistency across The spirit that motivated the founders of surveyors may not understand the ACCREDITATION AND QUALITY OF CARE the organization. For example, we Dena’ Nena’ Henash continues to inspire challenges faced in providing healthcare Beyond the challenges of geography, had a long-standing infection control the current generation as it looks to the in this type of location. Since we were there are also chronic health issues manual, but it was primarily focused future. accrediting not only our main facility within the Alaska Native community, on our large, more urban facility. It but also two of our rural clinics, it Following the 2016 AAAHC survey, including diabetes, heart disease, cancer, just didn’t have much guidance for our helped to have surveyors who had prior one surveyor observed, “This is an and behavioral health issues. rural health staff, who have far more experience and understood some of the extremely well run organization focused on the health and well-being of the patients it serves. The vision, “healthy people across generations,” drives activities across the organization. The definition of health is broad in scope, including spiritual, physical, mental, and emotional wellness.” s

TCC offers a full range of services including obstetrics care and women’s health.

6 ›› TRIANGLE TIMES | SUMMER 2017 IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION Surveyor spotlight

Since 2012, Ms. Primeau has been Ms. Primeau believes the greatest The word commitment rings true. Her surveying for AAAHC. She learned about benefit of AAAHC is its commitment professional career has been a testament the opportunity to survey while working to upholding expectations of the care to the pursuit of excellence in health care at the Concord Ambulatory Surgery provided in ASCs to the highest standards and is clearly a motivating force in Ms. Center. of quality and safety. “Understanding the Primeau’s work as a surveyor for AAAHC. rigors that an accredited center has had “I have been in the surgical services “Understanding the to meet or exceed in order to achieve industry for over 25 years and take rigors that an accredited that accreditation makes me feel more pride in ensuring the highest standard comfortable as a health care consumer of care for all patients. Being a surveyor center has had to when seeking care for myself or others.” for AAAHC provides me with a two- PRIDE IN LEARNING way street, so to speak, with regard to meet or exceed in Clearly the flame of the AAAHC mission learning about changes in the industry order to achieve that burns brightly in Ms. Primeau. She feels and sharing those with centers that that every center which undertakes I survey.” accreditation makes me the accreditation process has the BEVERLY PRIMEAU, RN When Ms. Primeau is not traveling the feel more comfortable as opportunity either to be very proud of country surveying ASCs or working her the services they provide or to learn, full time job, she is active in her roles as To say that Beverly Primeau has devoted a health care consumer change, and improve. “It is rewarding wife and as mother of a teenage daughter. her life to health care is certainly not for me as a surveyor,” she observes, “to “If we aren’t at her soccer games or hyperbole. Her credentials are impressive when seeking care for see best practices in action or to know practices, we enjoy camping, traveling, and her experience and scope vast. myself or others.” that organizations are learning from and playing with our three dogs. I also Ms. Primeau has been an operating room their experiences and working toward love to cook.” She purchases upwards of nurse for over 25 years and is certified “Dr. Paul Allen was our AAAHC survey providing a higher standard of care.” 50 pounds of lobster each year that she both as a registered nurse first assistant chair, and at the conclusion of the survey Annually she does anywhere between freezes and uses in her recipes. (CRNFA) and an ambulatory surgery told me I’d be a good surveyor. He asked three and eight surveys. In addition Currently she works as the Director of center administrator (CASC). Additionally, me to consider training for the position, to regular accreditation she is also Surgical Services at Elliot Hospital in she is a past Vice President of the which I did, and I decided to give it a try. credentialed for Medicare Deemed Status Manchester, New Hampshire, overseeing New Hampshire Ambulatory Surgery Although our previous surveys had all and surveys a wide variety of facilities inpatient and outpatient surgical services, Association. During her 11-year tenure, ended successfully, I felt the experience from single to multi-specialty ASCs. inpatient and outpatient endoscopy she was involved in the start-up of the of doing the work of a surveyor would “I remain current with the Standards and services, a free-standing ASC, and a Concord Ambulatory Surgery Center and, help prepare me for future surveys at our regulatory changes as part of my full-time free-standing endoscopic out-patient as the facility’s administrator, successfully facility and would broaden my credibility job and in my commitment to AAAHC.” department. s guided it through four AAAHC surveys. as an expert in my field.”

Notification of organizational changes

Accredited organizations must notify this topic. To simplify the process of list of the types of changes that should it before you fill it out. Save it again AAAHC in writing within 15 days of any communicating a change and expedite be reported. Once there, you’ll see a before you send it to notify@aaahc. significant organizational, ownership, approval, we’ve developed a standard link to a Change Notification Form that org as an attachment (along with any operational, or quality care events. template that can be found on our allows you to specify the change and supporting documents). Following Because “change” ranges from the website homepage (lower right) under see what (if any) additional supporting this process will help you meet all the simple—a new primary contact—to the “I want to…Notify AAAHC of a change documentation is required. requirements of a given change and complex—a new satellite location—we in my organization.” Once you access the form, be sure to streamline our approval process. s receive a lot of communication on The link takes you to a page with a save it to your computer and re-open

AAAHC Institute updates

OPIOID AND ANTIBIOTIC STEWARDSHIP and features a series of resources and content for most sections, current In 2016, the CDC reported that from checklists relevant to surgical/procedural research, and expanded references. 2000-2015 more than half a million settings, primary care settings, and all Copies of these toolkits may be ordered people in the U.S. died from drug providers. The publication includes an at www.aaahc.org/institute/Patient- overdoses. Additionally, 91 Americans overview of current research. Safety-Toolkits1/ s die every day from opioid overdoses. Along with opioids, another patient Relevant AAAHC Standards throughout safety issue was addressed in a toolkit the handbook address this issue released earlier this year: overprescribing in varying contexts, from Chapter of antibiotics. The toolkit, Antibiotic 2: Governance, Chapter 5.II: Risk Stewardship, features discussions of Management, Chapter 11: Pharmaceutical surgical and primary care considerations, Services, Chapter 16: Health Education, a hands-on guide for assessing your Chapter 17: Behavioral Health, to organizations’ antibiotic stewardship Chapter 25: Medical Home. Over the activities, and a full selection of past six months, AAAHC Institute has references for further investigation. published patient safety toolkits which REVISED AND UPDATED SURGICAL include current research and discuss best TOOLKITS practices for prescribing of opioids and Revised versions of our Ambulatory antibiotics. Surgery and VTE (Venous A new Patient Safety Toolkit, Opioid Thromboembolism) and Ambulatory Stewardship, focuses on opioid Surgery and Preventing Falls toolkits are prescribing within ambulatory settings now available. Each contains updated

IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION SUMMER 2017 | TRIANGLE TIMES ›› 7 © The Accreditation Association for Ambulatory Health Care. Volume 4 | Issue 3 | Summer 2017 7/17/4K

Diversity: The art of thinking independently together. - Malcolm Forbes

AAAHC has always prided itself on American College of Gastroenterology Association of periOperative Registered Speakers’ Bureau. maintaining a collaborative culture. (ACG) Nurses (AORN) Bringing the knowledge of Our Standards are developed and American College Health Association Society for Ambulatory Anesthesia AAAHC to you. accreditation decisions made by (ACHA) (SAMBA) members of the Board of Directors American College of Mohs Surgery We believe that diversity of perspective The current topics include: representing 17 healthcare specialty (ACMS) drives a more complete view of the • Common deficiencies and how associations: American Congress of Obstetricians & complicated healthcare environment. to avoid them ASCA Foundation Gynecologists (ACOG) Similarly, the AAAHC staff represents • How to prepare for a re- American Academy of Cosmetic Surgery American Dental Association (ADA) not only a diverse set of skills and accreditation survey (AACS) experience but also a wide range of American Gastroenterological • Using simulation-based drills to cultural backgrounds. American Academy of Dental Group Association (AGA) prepare for an emergency Practice (AADGP) The map below shows the countries American Society of Anesthesiologists • Linking peer review and American Academy of Dermatology from which our staff have come, (ASA) benchmarking to improve quality (AAD) either through immigration or as American Society for Dermatologic first generation U.S. citizens. s • Staying survey ready American Academy of Facial Plastic & Surgery Association (ASDSA) Reconstructive Surgery (AAFPRS) American Society for Gastrointestinal Contact [email protected] American Association of Oral & Endoscopy (ASGE) Maxillofacial Surgeons (AAOMS)

Hong Kong Kazakhstan

Poland

South Korea

Philippines

India Ghana Kenya

Australia

Chile

In this issue:

■ Tanana Chiefs Conference ■ In Memoriam: Dr. John Burke ■ Standard Bearer: 5.I.C.10 ■ Survey spotlight: Beverly Primeau ■ New look for 2018 Standards

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