An AAAHC quality improvement study passes when it shows six components, a purpose with a numeric baseline, a measurable time-bound goal, analysis of root causes, corrective actions, remeasurement and communication to leaders and staff. AAAHC Standard QUA.240 requires these studies whenever data collection reveals a problem or an improvement opportunity.
What QUA.240 asks for
AAAHC Standard QUA.240 states that the organisation demonstrates continuous improvement by conducting quality improvement studies when data collection reveals a problem or improvement opportunity. AAAHC does not prescribe a model, whether the IHI Model for Improvement, Lean, Six Sigma or DMAIC, but surveyors evaluate each study against six components.1
| Component | What AAAHC looks for |
|---|---|
| State the purpose | The problem, who it affects, why it matters, and the baseline expressed as a number |
| Set the goal | Measurable and time-bound, with benchmarking to guide a realistic target |
| Analyze the data | The root causes of the gap, documented |
| Implement corrective actions | Targeted actions tied to the causes found |
| Remeasure | Whether the goal was met, repeating the cycle if not, and remeasuring one or two more cycles for sustainability once it is |
| Communicate | Findings shared with leaders and staff, governing body review documented, lessons built into education |
v44 strengthened the guidance on data collection and outcomes measurement, and updated the Quality (QUA) category to standardise terminology across programs.23 Quality was among the top three deficiency areas in both surgical and primary care in the 2026 Quality Roadmap.4 QUA.210 also expects high-risk issues from risk management to trigger an improvement project with measurable goals, timelines and accountability.5
Pick a topic with data you already have
The best studies use data the practice already collects every week. AAAHC itself points to allergy documentation as a candidate. The 2026 Quality Roadmap found 17.9% of surgical and procedural organisations and more than 30% of primary care settings had room to improve CRD.210, and AAAHC recommends a targeted QI study with data before and after the intervention.6 Other topics with ready data include missed appointments, time to answer a new enquiry, complete written discharge instructions and results reviewed within a set time.
- Choose the problem from your data. Pick a measure where you can count the baseline, such as the share of records with allergy reactions and severity documented.
- Write the baseline as a number. For example, 71% of 60 sampled records in March.
- Set a goal and a date. For example, 95% by the end of June, checked against a benchmark where AAAHC publishes one.
- Find the causes. Walk the workflow. Where does the step get skipped, and why?
- Change the workflow. Make the step part of intake or rooming, with a prompt and staff education.
- Remeasure, then remeasure again. Repeat the same sample method. Once you meet the goal, measure one or two more cycles.
- Report to the governing body. Minute the review, and share the result with staff.
- Purpose, the problem ______ Who is affected ______ Baseline ______
- Goal, the target ______ By ______ Benchmark ______
- Analysis, the root causes ______
- Actions, what changed ______ When ______ Owner ______
- Remeasurement, the result ______ Goal met, yes or no ______ Next cycle ______
- Communication, governing body review on ______ Staff told on ______
What sinks a study
- A purpose with no baseline number.
- A goal with no date.
- Actions that do not match the causes found.
- A single remeasurement taken as proof of a lasting change.
- No record that the governing body reviewed it.
See how QI studies fit the wider survey in the AAAHC survey checklist, and how the records you sample should read in the clinical records guide. The AAAHC hub sets out the Quality category.
Questions
How many QI studies does AAAHC expect?
QUA.240 asks for studies whenever data collection reveals a problem or opportunity. The number depends on what your data show, and each study needs all six components.
Does AAAHC require a particular QI method?
No. AAAHC accepts any model, such as the IHI Model for Improvement, Lean, Six Sigma or DMAIC, as long as the six components are documented.
How many remeasurements are enough?
AAAHC asks you to repeat the cycle until the goal is met, then remeasure one or two more cycles to show the change has lasted.
Sources
- 1AAAHC, 2026April 2026 Triangle Times Today, procedure observation and the six components of a QI studyRead source
- 2AAAHC, 2025AAAHC Releases v44 Standards to Drive Excellence in Ambulatory Care (news release)Read source
- 3AAAHC, 2025Version 44 Standards Elevate Patient-Centered Care and Clarity, AAAHC newsletter, September 2025Read source
- 4AAAHC, 2026June 2026 Triangle Times Today, New 2026 Quality Roadmap Expands AnalysisRead source
- 5AAAHC, 2026March 2026 Triangle Times Today, Artificial Intelligence, AAAHC's Framework for Responsible ImplementationRead source
- 6AAAHC, 2026August 2026 Triangle Times Today, AAAHC's New v45 Standards Provide Guidance for Artificial Intelligence UseRead source
Written by the wai team from Accreditation Association for Ambulatory Health Care guidance, checked on 15 October 2026. This is guidance, not legal advice. AAAHC does not endorse wai or any software.