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Accreditation for Ambulatory Health Care
5.I. Quality Management and Improvement: Quality Improvement Program Standards
5.I.C. Ongoing data collection processes are in place to measure quality and to identify quality-related problems or concerns.
5.I.C.4. Performance is compared to internal and external benchmarks
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5.I. Quality Management and Improvement: Quality Improvement Program Standards
5.I.A. The organization has a written quality improvement program.
5.I.A.1. Program addresses full scope of services and how services are assessed for quality
5.I.A.2. Program identifies individuals responsible for development, implementation, and oversight
5.I.A.3. Program includes participation by health care professionals, one of whom is a physician or dentist
5.I.A.4. Program purpose and objectives are identified
5.I.A.5. Program describes ongoing data collection processes used to measure quality and identifies problems or concerns
5.I.A.7. Program is evaluated annually
5.I.B. The quality improvement program includes processes to ensure communication of the results of quality improvement activities.
5.I.B.1. Results of program are reported to the governing body
5.I.B.2. Results of program are reported throughout organization
5.I.C. Ongoing data collection processes are in place to measure quality and to identify quality-related problems or concerns.
5.I.C.1. Program processes include analysis of results of peer review activities
5.I.C.2. Periodic audits of critical processes are conducted
5.I.C.3. Program includes ongoing monitoring of important processes and outcomes of care
5.I.C.4. Performance is compared to internal and external benchmarks
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Element of Compliance
Performance is compared to internal and external benchmarks
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