Assessment then Accreditation: The Next Logical Step

Student Affairs Assessment ConferenceEmory UniversityOctober 11, 2010

Michael J. Huey, MD

Executive DirectorEmory University Student Health and Counseling ServicesSurveyorAccreditation Association for Ambulatory Health Care, Inc. (AAAHC)

The take-home message of today’s presentation:

It is OK to leave now if that gives you what you need. . .

Objectives of this presentation:At the conclusion of this presentation, attendees should be able to:

1.Describe the benefits of national accreditation for student health and counseling services2.Discuss the types of accreditation available3.Review assessment and quality improvement standards of national accrediting agencies4.Describe the accreditation process, including a typical accreditation survey5.(Find something fun to do in Atlanta after the session is over)

Here’s something fun to doat 9:37 pm tonight. . .

Disclaimers . . . and Credentials • I strongly believe in the

value of accreditation (which can be viewed as passionate and/or biased, depending upon your preference)

• I have been a Student Health Director/Executive Director for 20 years and have been through 6 accreditation surveys at my SHCSs (AAAHC and Joint commission)

• I have been through 3 first-time accreditation surveys at 3 different universities

• I have been a surveyor for AAAHC for 6 years and I will soon reach my 20th survey of college health services

• This year AAAHC converted its “volunteer” surveyors to employees/contractors for tax reasons (theirs, not ours)

• I now take vacation time to do AAAHC surveys (ouch!).

Therefore, once you have an active and successful Assessment/Quality Improvement process in place, national accreditation of your service is the next logical step

Zoo Atlanta has Pandas

Accreditation:• Is a process that allows a

healthcare organization to measure the quality of its services and performance against nationally recognized standards

• Involves self-assessment as well as a thorough review by outside trained expert surveyors with extensive experience in the healthcare environment

• Provides a recognized symbol to others that the organization is committed to high quality and that it meets national standards

Accredited Student Health Centers:AAAHC (166 as of February 2010)ALABAMA• University of Alabama-Tuscaloosa*ARIZONA• Arizona State University*• Northern Arizona University*• The University of Arizona*ARKANSAS• University of Arkansas-Fayetteville*CALIFORNIA• California Polytechnic State University-

San Luis Obispo• California State Polytechnic University-

Pomona*• California State University-Bakersfield*• California State University-Chico*• California State University-Dominguez

Hills• California State University-East Bay*• California State University-Fresno*• California State University-Fullerton*• California State University-Long Beach*• California State University-Los Angeles

• California State University-Northridge*• California State University-Sacramento*• California State University-San

Bernardino• California State University-San Marcos • California State University-Stanislaus*• Humboldt State University• Loyola Marymount University*• San Diego State University• San Francisco State University• San Jose State University• Santa Clara University*• Sonoma State University• Stanford University*• University of California-Berkeley*• University of California-Davis*• University of California-Irvine*• University of California-Los

Angeles*• University of California-San Diego• University of California-Santa

Barbara*• University of Southern California*

AAAHC (continued)

COLORADO• Colorado College*• Colorado State University*• University of Colorado-Boulder*• University of Denver*CONNECTICUT• University of Connecticut-Storrs*DELAWARE• University of Delaware*FLORIDA• Florida State University*• University of Central Florida*• University of Florida*GEORGIA• Emory University*HAWAII• University of Hawaii at ManoaILLINOIS• Illinois State University*• Northern Illinois University*• Northwestern University*• Southern Illinois University-

Carbondale*• University of Illinois at Urbana-

Champaign*• Western Illinois University*

INDIANA• Indiana University-Bloomington• Indiana University Purdue• University at IndianapolisIOWA• Iowa State University*• University of Northern Iowa*KANSAS• Kansas State University*• University of Kansas*KENTUCKY• University of Kentucky*LOUISIANA• Louisiana State University*• Tulane University*MAINE• Colby CollegeMARYLAND• Frostburg State University*• Johns Hopkins University*• Salisbury University*• University of Maryland-College

Park*

AAAHC (continued)

MASSACHUSETTS• College of the Holy Cross*• Harvard University*• University of Massachusetts-Amherst*• University of Massachusetts-Boston*MICHIGAN• University of Michigan-Ann Arbor*• Western Michigan University*MINNESOTA• Bemidji State University*• Minnesota State University-Mankato*• Minnesota State University-

Moorhead*• Saint Cloud State University*• University of Minnesota-Duluth*• University of Minnesota-Twin Cities*MISSISSIPPI• Mississippi State University*• University of Southern Mississippi*MISSOURI• Missouri State University• Saint Louis University• University of Missouri-Columbia*• Washington University in St. Louis*

NEBRASKA• University of Nebraska-Lincoln*NEVADA• University of Nevada-Reno*NEW HAMPSHIRE• University of New Hampshire*NEW JERSEY• Drew University*• Princeton University*• Rutgers University-Camden• Rutgers University-Newark*• Seton Hall UniversityNEW MEXICO• New Mexico State University*NEW YORK• Barnard College*• Buffalo State College/State• University of New York*• Columbia University*• Cornell University*• Hudson Valley Community College*• Ithaca College*• New York University*• Rensselaer Polytechnic Institute*• Rochester Institute of Technology*

AAAHC (continued)

NEW YORK• State University of New York-Albany*• State University of New York-Alfred• State University of New York-

Binghamton• State University of New York-

Brockport*• State University of New York-

Cobleskill*• State University of New York-Cortland*• State University of New York-Geneseo*• State University of New York-Oswego*• State University of New York-Potsdam*• Stony Brook University*• Syracuse University*NORTH CAROLINA• Appalachian State University*• East Carolina University*• North Carolina State University*• University of North Carolina at

Greensboro*• Winston-Salem State University*NORTH DAKOTA• North Dakota State University*• University of North Dakota*

OHIO• Bowling Green State University*• Cleveland State University*• Kent State University* Miami

University*• University of Toledo*OKLAHOMA• Oklahoma State University-Stillwater*• University of OklahomaOREGON• Oregon State University*• Southern Oregon University*• University of Oregon*PENNSYLVANIA• Carnegie Mellon University*• Clarion University*• Dickinson College*• Franklin & Marshall College*• Haverford College*• Kutztown University*• Pennsylvania State University*• Pennsylvania State University-

Altoona*• Slippery Rock University*• University of Pittsburgh*

AAAHC (continued)

SOUTH CAROLINA• Columbia College*• University of South Carolina-

Columbia*SOUTH DAKOTA• University of South Dakota*TEXAS• Baylor University*• Sam Houston State University*• Southern Methodist University*• Texas A&M University-College

Station*• Texas State University-San Marcos*• University of Texas-Austin*• University of Texas-Pan American*VERMONT• University of VermontVIRGINIA• College of William and Mary*• Old Dominion University*• Radford University*• Virginia Commonwealth University*• Virginia Tech*

WASHINGTON• Central Washington University*• University of Washington• Washington State UniversityWISCONSIN• University of Wisconsin-Madison*• University of Wisconsin-Milwaukee*• University of Wisconsin-• Oshkosh*• University of Wisconsin- Whitewater*WYOMING• University of Wyoming*

Joint Commission (23 as of February 2010)CALIFORNIA• Los Angeles Mission CollegeCONNECTICUT• Yale University*COLORADO• University of Northern Colorado*DISTRICT OF COLUMBIA• Georgetown University*GEORGIA• University of Georgia*INDIANA• University of Southern IndianaMASSACHUSETTS• Massachusetts Institute of

Technology*MICHIGAN• Michigan State University*NEW YORK• Crouse Hospital School of Nursing*• Siena College*• University of Rochester*

NORTH CAROLINA• University of North Carolina at

Chapel Hill*• University of North Carolina at

Charlotte*OHIO• Ohio State University*PENNSYLVANIA• University of Pennsylvania*RHODE ISLAND• Brown University• University of Rhode Island*SOUTH CAROLINA• Clemson University*TENNESSEE• University of Tennessee-Knoxville*TEXAS• Texas Tech University*UTAH• University of Utah*VIRGINIA• University of Virginia*

The Value of Accreditation for the Organization• Serves as a measurement of

professional achievement and quality of care

• Serves as a constructive learning experience for the staff and organization (accreditation is meant to be educational and consultative in nature, not punitive)

• Recognized by colleagues, other healthcare organizations and insurance industry (including third-party payors and liability carriers)

• Recognized by the general public (even students!) and can be used as a marketing tool

• Keeps your assessment process on task, robust, focused and worthwhile

• Allows organization to join the “family” of accredited SHCSs

• “Forces” an organization to undergo an extensive process of self analysis, peer-to-peer review, and policy/ procedure refinement

The History of Accreditation

• 1918: The American College of Surgeons fosters the hospital standardization movement, drawing up “minimum standards.”

• 1940: 81% of hospitals surveyed now meet minimum standards.

• 1949: Need for an independent, voluntary, non-profit accrediting agency voiced.

The History of Accreditation (continued)

• 1950: The Joint Commission on the Accreditation of Hospitals (JCAH) is formed by:

▫ American College of Surgeons▫ American Medical Association▫ American College of Physicians▫ American Hospital Association

But what if the JACH is a bad fit?• 1979: The Accreditation

Association for Ambulatory Health Care (AAAHC) is founded by a number of organizations, including:▫ American College Health

Association▫ American College of

Occupational and Environmental Medicine

▫ American Society for Dermatologic Surgery

▫ American Academy of Facial Plastic and Reconstructive Surgery

▫ National Association of Community Health Centers

The Margaret Mitchell House

AAAHC

• 1997: Maggie Bridwell, MD, former President of ACHA and Director of University of Maryland Student Health Service, is named President of AAAHC

• 2009: AAAHC surpasses 4,000 accredited organizations

Joint Commission v. AAAHC

• $15,000 in 1995 at University of Florida

• Surveyors paid, many survey as a career

• Carefully look at credentials and privileging, including primary source verification

• Very concerned about quality control and improvement

• Chapters divided by process and content

• Very focused on facilities

• Unannounced surveys

• $6,400 in 2010 at Emory University

• Surveyors paid (no longer “volunteers”), selected to fit the organization surveyed

• Carefully look at credentials and privileging, including primary source verification

• Very concerned about quality control and improvement

• Chapters divided by departments (lab, x-ray, etc.)

• Very focused on care of patients

• Scheduled surveys

AAAHC Standards 2010CORE STANDARDS

• Rights of Patients• Governance• Administration• Quality of Care Provided• Quality Management and

Improvement• Clinical Records and

Health Information• Infection Prevention and

Control and Safety• Facilities and Environment

ADJUNCT STANDARDS

• Anesthesia Services• Surgical and Related Services• Pharmaceutical Services• Pathology and Medical Lab Services• Diagnostic and Other Imaging Services• Dental Services• Other Professional and Tech Services• Health  Promotion• Behavioral Health Services• Teaching and Publication• Research Activities• Overnight Care and Services• Occupational Health Services• Immediate/Urgent Care Services• Emergency Services• Others (Managed Care, Radiation

Oncology, Lithotripsy, others)

Let’s focus on AAAHC Chapter 5:Quality Management and Improvement

Chapter 5 is divided into three subchapters:

•Subchapter I: Peer Review•Subchapter II: Quality Improvement Program•Subchapter III: Risk Management

In striving to improve the quality of care and to promote more effective and efficient utilization of facilities and services, an accreditable organization maintains an active, integrated, organized, peer-based program of quality management and improvement that links peer review, quality improvement activities and risk management in an organized, systematic way

Subchapter I: Peer review• Healthcare professionals are

involved in the development and application of the criteria used to evaluate the care they provide

• Peer review is not just restricted to physicians

• Peer review is a part of the employee’s annual performance evaluation and is used as a part of the process for granting clinical privileges.

• Peer review results are shared (in aggregate) with the governing body

• Healthcare providers are given access to continuing education

• Organization monitors licensure and certifications of healthcare providers

Subchapter II: Quality Improvement Program• The QI program is broad in

scope and addresses clinical, administrative and cost-of –care issues, as well as actual patient outcomes, including the safety of patients

• A specific committee oversees the QI program and representation is broad based

• Both internal and external benchmarking are performed

• The QI program is evaluated for overall effectiveness at least annually

• Findings must be reported throughout the organization, including to the governing body

• QI studies written reports demonstrate the classic “QI loop”

The Classic QI Loop

Subchapter III: Risk Management• A designated person or

committee is responsible for the risk management program and reports to the governing body

• Elements of the program include:▫ Consistent application of

risk management principles throughout the organization

▫ Methods by which a patient can be dismissed from care

▫ Reporting, reviewing and appropriate analysis of all incidents

▫ Review of all complaints

Stone Mountain

Risk Management• Elements of the risk

Management program (continued):▫ Communication with the

professional liability carrier

▫ Impaired healthcare professionals

▫ Establishment and documentation of coverage after normal working hours

▫ Methods of preventing unauthorized prescribing

▫ Education in risk management is provided to all staff

Let’s Eat!

If Time: A Walk through the Survey Process

Pre-Survey

• Application• Pre-survey questionnaire

and supporting documents• AAAHC determines length

of needed survey (usually 1 ½ to 2 days), number of surveyors and cost

• Selection of survey team and date

• Organization posts Notice of Survey

The Survey

• Opening orientation conference

• Tour of the facility• Tour of special units• Inspection of facilities• Review of clinical records• Individual interviews• Review of QI program

(and meeting with committee)

• Review of governance and administration

• Summation conference (Consultative comments!)

A Walk through the Survey Process (continued)

Post-Survey Process

• Surveyor(s) writes up the survey and submits to AAAHC

• Accreditation Committee review

• Preliminary Decision rendered

• Copy of survey report to the organization

• Opportunity for organization to submit corrections and additional information

Final Decision

• 3 year accreditation• 1 year accreditation• Provisional 6 month

accreditation• Deferral• Denial

Reminder about the take-home message of today’s presentation:

Reminder about something fun to doat 9:37 pm tonight. . .

Q and A

• AAAHC at: www.aaahc.org • Joint Commission at:

www.jointcommission.org• Visit our EUSHCS website at:

www.studenthealth.emory.edu• Michael Huey at:

mhuey@emory.edu404-712-8652