The most successful healthcare organizations are run by leaders who champion quality and patient safety.

“They develop and support the policies and procedures that guide frontline staff,” says Pearl S. Darling, MBA, executive director, ambulatory care services, The Joint Commission.

Successful surgery centers also involve their staff in the entire accreditation process to ensure both understanding and engagement, she adds. Surgery centers that receive notice of accreditation deficiencies should review any systemic issues or underlying factors that could have prevented these deficiencies.

The Joint Commission offers a Robust Process Improvement tool that provides a technique for quickly identifying the root cause of a problem.1

Deficiencies in conducting quality improvement (QI) studies remain relatively high, but the overall deficiency in QI programs had declined slightly, says Naomi Kuznets, PhD, vice president and senior director, Accreditation Association for Ambulatory Health Care (AAAHC) Institute for Quality Improvement. “Conducting QI is not intuitive for many providers and staff,” she explains. “They lack education on how to do so.”

Also, most employees at a surgery center wear multiple hats, and the resources necessary to conduct QI studies are limited, Kuznets adds. “Governance support and key staff and providers need to be involved,” she advises. “The absence of a basic understanding of the process and pitfalls, including poorly described goals and measures that fail to identify key performance factors, and the inability to focus on important issues are also problems.”

AAAHC has found that healthcare professionals are better now than in past years about complying with standards related to using emergency equipment and developing a safe evacuation plan, Kuznets notes.

This could be attributed to educational resources, such as AAAHC’s emergency drills toolkit and webinars. Healthcare organizations also are more aware of their own vulnerability to natural and man-made disasters due to media coverage of where problems occur, Kuznets observes.

There is an increasing proportion of millennials in the work place who have grown up with more exposure to drills and safety measures than previous generations. “Also, having increasing resources from the AAAHC may have fostered a better understanding of the importance of ongoing staff development and improvement,” Kuznets says.

Surgery centers can follow AAAHC’s 1095 Strong practice, which refers to their being prepared all 1,095 days of the accreditation term. “They use systems and tools, such as reminders, prompts, in-services, and other education/resources, to help them work pre-emptively and effectively,” Kuznets says.


  1. Grazman D. Getting an ROI from Robust Process Improvement (RPI). The Joint Commission, Feb. 23, 2018. Available at: Oct. 24, 2019.