The Poland File


  • Senior vice president of accreditation services, Accreditation Association for Ambulatory Health Care, Skokie, Ill.
  • Director of Health Facilities Accreditation Program and practice management, American Osteopathic Association, Chicago
  • Regional quality and risk manager, Ramsay Mental Health, Ramsay Health Care, Sydney
  • Compliance manager, Moran Health Care Group, Sydney


  • Doctor of nursing candidate, Rush University, Chicago
  • Health policy fellowship, Ohio University, Athens
  • Master in nursing, Western Sydney University, Australia
  • Bachelor of nursing, Avondale College, Cooranbong, Australia
  • Post-graduate certificate, NSW Institute of Psychiatry, North Parramatta, Australia

Volunteer Work

  • Registered nurse, Old Irving Park Community Clinic, Chicago

As Senior Vice President of Accreditation Services for the Accreditation Association for Ambulatory Health Care (AAAHC), Therese Poland works with one of the health care field’s growing segments. This month, she talks about the challenges facing ambulatory facilities as they serve ever more patients in different ways. 

What are your responsibilities and background? 

My responsibilities as vice president of accreditation services include executive leadership for the accreditation and certification of more than 6,100 health care organizations. This includes all activities related to surveys, eligibility and accreditation processes, account management, and state and federal deeming compliance requirements. I also frequently serve as a technical expert in areas of accreditation and orthopedic certification. 

What brought you to AAAHC?

I worked as a registered nurse overseeing quality and risk management in a health system in Australia. During this time, I was privileged to work closely with engineering professionals within existing hospitals and in the design of new health care facilities. Seven years ago, I decided to make a switch to the other side of compliance and began my journey with accreditation organizations and regulatory compliance in the United States. 

What types of ambulatory facilities does AAAHC accredit? 

AAAHC accredits all types of ambulatory facilities, such as ambulatory surgery centers (ASCs), office-based surgery centers, primary care organizations, dental practices, government entities and retail clinics, to name a few.

Has increased acuity levels of patients in the ambulatory setting made managing these facilities more challenging? 

Recent attention in the ambulatory setting has been on the acceptance of higher-acuity patients. Deciding to increase acuity levels in the ambulatory setting requires careful consideration. ASCs should give attention to risk tolerance, resource allocation, clinical policies, capital investment and infrastructural requirements.

As procedures continue to expand in the outpatient surgical setting, comorbidities will impact how care is provided and the type of equipment and resources that may be needed to provide safe care. Facilities designed for lower acuity were once prevalent, but they are now finding themselves short of compliance with the new codes required for higher-acuity procedures. While higher-acuity care in the ASC setting may be cost driven, ensuring compliance with applicable design codes is paramount to patient safety.

What are some of the engineering challenges you’re seeing in ambulatory facilities? 

Ambulatory facilities have experienced significant changes to life safety requirements. Now more than ever, engineers need to understand the adoption of the requirements related to the 2012 editions of [the National Fire Protection Association’s] NFPA 99, Health Care Facilities Code, and NFPA 101, Life Safety Code®

While the codes driving requirements for engineered systems are well known to qualified design professionals, many of the organizations owning or operating ASCs have only their faith in the qualifications of the design engineers and the occupancy approval process of local or state officials to go on. 

Very few organizations are aware of the documentation required to be in their possession relative to initial system acceptance and, as such, are cited during qualified surveys for not meeting NFPA requirements. 

Getting it wrong during the design or redesign of a health care facility is costly and, in an extreme case, this can result in their ASC being denied Centers for Medicare & Medicaid Services approval for certification.

What are some of the environmental challenges you’re seeing?

Ambulatory surgical centers must have a functionally safe and sanitary environment. Organizations running ASCs often feel blindsided by NFPA operational requirements related to inspection, testing and maintenance (ITM) to the degree that a surprising number have entered into maintenance contracts that fall significantly short of compliance. This unfortunate situation is generally attributed to a variety of factors, from nobody informing them NFPA has operational requirements to successful passage of numerous prior surveys that ignored the requirements entirely. Then, there are maintenance vendors that enter into contracts for ITM of systems with high-frequency requirements but offer ITM frequencies that skip a great number of required activities, such as a semiannual ITM site visit when the related system has weekly, monthly or quarterly requirements. A further complication comes from changes in requirements of codes or standards that apply to existing as well as new facilities — the first an organization may hear of them is often during a survey for which they suddenly find themselves unprepared.

How does AAAHC encourage collaboration between health facility professionals and clinical staff? 

Part of my role is to participate in a high-level review of complex reports. During this activity, partnering with a life safety consultant adds dimension and value to the interpretation and provides clarity on the direction for recommendations. This supports the account management team and aids in the refinement of training and timely feedback for surveyors.

Similarly, this applies to health and life safety professionals within the ASC. There are several domains that require collaboration, such as infection control, emergency preparedness and design of patient flow. 

The life safety professional’s expertise is in design, construction and maintenance of the physical environment. This, coupled with clinical expertise, is optimal in the development and maintenance of a safe patient-care environment. For example, when planning reconstruction or renovation, a formal risk assessment for interim and life safety measures is a requirement that demands a team effort. 

The risk assessment should document specific methods to reduce the potential for transmission of airborne and waterborne biological contaminates along with mitigating life safety issues during the construction process. 

Why would hospitals with standalone ambulatory facilities choose to have those facilities accredited by AAAHC versus another accrediting group? 

AAAHC is the leader in ambulatory accreditation. In fact, we recently launched a new brand awareness campaign to celebrate our 40-year history. Selecting AAAHC accreditation strengthens an organization’s commitment to patient safety and continuous quality improvement. 

Adherence to rigorous standards of care and safety will help to ensure an organization delivers quality every day — for 1,095 days of the accreditation cycle. The drivers of AAAHC’s “1095 Strong” transformational movement and call to action include ongoing engagement, excellence and relevance, accelerated readiness, accountability and surveyor expertise.