Q&A AAAHC report highlights top problem areas

Editor’s note: Each year, the Accreditation Association for Ambulatory Health Care (AAAHC) Institute creates a Quality Roadmap report highlighting different findings related to improving the accreditation process. In the 2016 report, AAAHC found the three top deficiency categories to be:
•    Privileging, credentialing, and peer review
•    Quality improvement programs
•    Documentation

The following is an edited Q&A with Cheryl Pistone, RN, MA, MBA, AAAHC clinical director of ambulatory operations, about the deficiencies and what facilities can do to improve.

BOAQ: How do the top deficiencies this year compare to last year? Has anything changed?
Pistone: The top deficiencies tend to stay fairly consistent in the categories. Credentialing, privileging, and peer review show up almost every year. This year, we also saw deficiencies in quality improvement studies and document`tion, and for surgical organizations, we saw deficiencies in safe injection practices.

BOAQ: Can you expand more on the common issues or mistakes around credentialing, privileging, and peer review?
Pistone: Let’s start with credentialing where a lot of the most common mistakes are:
•    Getting the governing body to review primary source verification
•    Completion of expired reappointment applications
•    Failure to incorporate peer review into credentialing is a fairly common mistake.

With privileging, we see a lot of privileges granted for procedures not provided by the organization. A lot of times what organizations do is get a privilege list from a hospital that has an expansive procedure list and use that. Often, they are not procedures that are available at the facility we’re surveying. It’s like blanket privileging rather than a list tailored to the procedures provided by the organization.

And it doesn’t make sense to [give] privileges for something your facility can’t provide. You have approved equipment at your facility so you know what can be performed safely there and that’s all that should appear on the privilege list.

Sometimes we’ll see delineation of privilege forms that don’t have a signature, or aren’t dated, or have passed the expiration date. 

Sometimes the medical director’s privileges aren’t reviewed by a different provider (in other words, the medical director signs off on their own privileges.)

What we see with peer review is that:
A. Sometimes it’s not done at all.
B. That it’s not always done by similarly licensed peers.

A lot of the time, organizations don’t connect the fact that you should include peer review within credentialing; that’s kind of the last step that gets missed. They might do peer review, but they don’t consider putting it as part of the re-credentialing process and that’s important. If you have a provider who gets poor marks from his or her peers, do you really want to recredential them?
 

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