AAAHC Releases Report Identifying High Compliance Areas and Improvement Opportunities

June 24, 2020

AAAHC recently released its 2020 Quality Roadmap report, which provides a thorough analysis of data from 1,488 surveys conducted in 2019. Health care organizations can utilize this tool to identify themes that deserve special attention as they pursue ongoing quality improvement throughout the accreditation period. While most deficiencies are comparable to previous years’ findings, given the COVID-19 pandemic, the report underscores the need to address Standards related to infection prevention, safe injection practices, and emergency preparedness.

“The AAAHC Standards focused on infection prevention and control have never been more important. Today, health care organizations need to be even more vigilant about adherence to these practices to promote employee and patient safety,” said Noel Adachi, MBA, president and CEO of AAAHC. “The Quality Roadmap, along with other AAAHC resources such as educational programs and webinars, is designed to help organizations integrate best practices at their facilities throughout the 1,095 days of the accreditation term.”  

The 2020 AAAHC Quality Roadmap examines accredited organization compliance ratings for current AAAHC Standards based on onsite surveys conducted January 1–December 31, 2019. Organizations surveyed include ambulatory surgery centers (ASC), Medicare Deemed Status ASCs (MDS ASC), office-based surgery practices (OBS), and primary care settings (PC).  

Findings on High-Deficiency Standards

The cumulative findings suggest that facilities continue to face challenges related to quality improvement studies and documentation. The most common documentation deficiencies include missing information in the patient clinical record on allergies/sensitivities and no evidence that medication reconciliation was performed. The analysis further indicates that other top deficiencies cited in more than 10% of survey ratings were consistent with previous years, including those related to credentialing and privileging, infection prevention/safe injection practices, and emergency preparedness.

Findings on High-Compliance Standards  

AAAHC’s analysis shows that AAAHC-accredited organizations demonstrated high compliance with several Standards. The facilities surveyed showed improvement in several key areas, which are organized by Non-Medicare and Medicare Deemed Status Standards, including:

Non-Medicare Deemed Status Standards

  • Supporting ongoing professional development
  • Transferring a patient’s care from one health care professional to another
  • Educating operators of newly acquired devices or products to be used for patient care
  • Maintaining strict confidentiality on records that contain clinical, social, financial, or other data about a patient, except when otherwise required by law
  • Ensuring pharmaceutical services are directed by a qualified licensed provider

Medicare Deemed Status Standards

  • Implementing preventive strategies targeting adverse patient events
  • Improving the professional competence, skill, and performance of health care professionals
  • Providing convenient access to reliable, up-to-date information pertinent to the clinical, educational, administrative, and research services
  • Encouraging health care professionals to participate in educational programs and activities
  • Ensuring that concern for the cost of care is present throughout the organization

“In line with AAAHC’s 1095 Strong, quality every day philosophy, which promotes ongoing commitment to quality improvement and patient safety, the 2020 Quality Roadmap can help ambulatory providers better develop and strengthen their policies, procedures, and practices,” said Adachi. “This requires a team effort. We encourage organizations to review and discuss the Quality Roadmap findings and work together to drive collaboration and help all team members focus on improving the quality of care they provide.”

The 2020 AAAHC Quality Roadmap is available for download at


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