“Quality Program for
Surgery Centers
Marcy Sasso, CASC
The Objective of this Presentation
is to Describe:
• What A Quality Program Entails
• Areas of Quality Measurement
• Methods of Data Collection
• Implementation
• Tying in Benchmarking to your QA Program
• GAIN CONFIDENCE in your QUALITY Program
Quality Program- It’s a Name
• Quality Assurance QA
• Quality Improvement QI
• Performance Improvement PI
• Quality Assurance Performance Improvement QAPI
• Total Quality Management TQM
Elements of Your Quality Program
From The Booking Form
Pre-op Phone Call
Patient Registration
Pre-op Assessment
Consents
Medical Record Documentation
Time- Out
Recovery
To The Post-op Phone Call
Quality Indicators… Just a FEW
Infection Control
BBP Exposures
Volume and Procedure Statistics
Specimen Errors
Occurrence Reports
Logs
Procedure Complications
Patient Wait Times
Sedation/Anesthesia Complications
Staffing Levels
Turnover Rate
Start Times
Cancellation Rates
Safe Injection Practices
Scope Reprocessing
Poor Preps
Continual Quality Examples
Contracts
Preventative Maintenance
Patient Satisfaction
Chart Audits
Peer Review
Credentialing
Minutes *
Quarterly Meetings
Education
In-Services
*Document all QA Activity
Drills, Safety & Rounds
Malignant Hyperthermia- General Anesthesia
Annually
Fire, With Scenario, And Transmission Form
Quarterly
Disaster, With Scenario
Every 6 months
Code Blue
Annually
Fire Extinguishers, Eye Wash, Facility Rounds
Why Have a Quality Program Anyway?
It’s REQUIRED for CENTER ACCREDIDATION
TJC
AAAHC
AAAASF
Medicare- CMS
To PROVIDE QUALITY PATIENT CARE
CMS Regulations Q-0081 416.43
416.41
The ASC must have a governing body that assumes full legal responsibility for determining,
implementing, and monitoring policies governing the ASC's total operation. The governing body has
oversight and accountability for the quality assessment and performance improvement program, ensures
that facility policies and programs are administered so as to provide quality health care in a safe
environment, and develops and maintains a disaster preparedness plan.
416.43 (d)(1)
Every ASC must undertake one or more specific quality improvement projects each year
*416.43 (d)(2)
ASC must document the projects being conducted, include analysis and explain actions and results.
The ASC must establish ongoing quality indicators to measure, track, and analyze data collected.
*The QAPI program must include infection control, radiology services and contract services.
Mandatory CMS Reporting
Patient Burn
Patient Fall
Appropriate Hair Removal
Hospital Transfer / Admission
Prophylactic Antibiotic Timing
Wrong Site, Side, Patient, Procedure Or Implant
ASCs that fail to successfully report will face a 2% facility fee reduction in future year's rates
Safe Surgery Checklist
ASC-6 Assess whether an ASC uses a safe surgery checklist
May employ any checklist as long as it addresses effective communication and safe
surgery practices in each of three peri-operative periods:
 Prior to administering anesthesia,
 Prior to incision, and
 Prior to the patient leaving the operating room
Applies to all ASCs, including GI endoscopy centers
Measurement from January 1, 2012 through December 31, 2012
Web Based Reporting via Quality Net
Selected Procedures
ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures*
Procedure Category Corresponding HCPCS Codes:
Cardio vascular /Eye /Gastrointestinal /Geni to Urinary
Musculoskeletal / Nervous System / Respiratory/Skin
Reporting via Quality Net (www.qualitynet.org)
Influenza Vaccination
ASC- 8 Influenza Vaccination Coverage Among Health Care Workers
Definitions Pending, But Appears Hcw Will Include:
Staff On Facility Payroll, Students And Volunteers
Licensed Independent Practitioners,
(E.G. Physicians, Advance Practice Nurses And Physician Assistants)
Measurement Begins With Immunizations For The Flu Season
Oct. 1, 2014 thru March 31, 2015;
for CY 2016 payment determination
ASC 9-11 New Reporting
Measures 9-11 Cover Percentages Of Performance On Chart-abstracted Sample
Data For Colonoscopies And Cataract Surgeries
All Ascs, Regardless Of Specialty Or Case Mix, Will Be Required To Report Them.
April-December 2014 dates of service
How to Begin the Process
Have a Meeting with Your Team
What Is A Problem Area Or Trend You Are Seeing At Your Center
And Want To Improve Upon? Are you doing ROUNDS?
 Patient Satisfaction
 Lower Revenue
 Cancellations
 Morale
 Turnover Times
A dialog Needs to Occur, to Effectively Decide on what Needs to be
Studied and Possibly Revised
Ten Step Template
Medical Records
1.
Purpose
2.
Identification of the performance goal
3.
Description of the data that will be collected
4.
Evidence of Data Collection (not the conclusion)
5.
Data analysis that describes the findings
6.
A comparison of the organizations current performance in the area of study against the previously identified performance goal. 7. Implementation
of the corrective actions i.e., interventions, to resolve the identified problem.
7.
Re-measurement ( a second round of data collection and analysis) of the problem to determine objectively whether the corrective actions, i.e.,
interventions, have achieved and sustained demonstrable improvement.
8.
Re-measurement ( a second round of data collection and analysis) of the problem to determine objectively whether the corrective actions, i.e.,
interventions, have achieved and sustained demonstrable improvement.
9.
If the initial corrective action(s) did not achieve and or sustain the desired improved performance, implementation of additional corrective
actions(s) and continued re measurement until the problem is resolved or is no longer relevant
10.
Communication of the findings of the quality improvement activities to the governing body and throughout the organization as appropriate, and
the findings were incorporated into the organization's educational activities.
Administrator/ Director of Nursing ___________________________ Date ______________
Medical Director __________________________________________ Date ______________
# 1 Purpose
Medical Records
Describe The Suspected Problem Or Concern;
Why Is It Important For The Center To Address This Problem
Complaints
Patient Safety
Financial Impact
During an audit, medical record charting was substandard and not meeting the
requirements of an accurate patient record. Medical Record errors/non-compliance may
lead to patient safety issues as well as risk management areas of concern.
# 2 Identification of the Performance Goal
Medical Records
Where Do We Want To Be?
Expected Outcome/Goal: 100% Compliance of the Required Medical
Record Elements
Actual Outcome: Initial study, TBD
# 3 Description of the Data that will be
Collected
Medical Records
A Chart Audit Tool was Developed to Collect Data for Measurement. It
was Determined that The Following Areas of the Patient Chart would be
Audited. The Audit will be Comprised of the Following Items:
• Anesthesia Consent
• Anesthesia Orders
• Physician Orders
• Medication Reconciliation Form
• History & Physical
# 4 Evidence of Data Collection
Medical Records
(This is not the conclusion)
See Audit Tool for Dates of Collection: Sheet Attached
Spreadsheet, computer reports, audit, or
observation
# 5 Data Analysis
Medical Records
Describes the findings, Frequency or Severity of the Problem, how often
is it Occurring and Identify the Source of the Problem.
(Initial) 30 Medical Records will be audited by the DON, every month until 100%
compliance is reached. After the initial audit it was evident that areas of the
records were not 100% compliant.
Frequency: The Nurses and Physicians have been inconsistent with accurate
documentation of the medical records per policy.
Severity: This can lead to miscommunication and patient safety issues regarding
timely patient care.
# 6 A Comparison of the Center’s Current
Performance
Medical Records
Analyze Your Data
(Initial TBD)
Is there an Increase or Decrease ,where?
Do you Note a Trend?
Is this Trend an Outlier or a Pattern?
Are you Using the Same Method to Collect the Data?
# 7 Implementation of the Corrective
Actions
Medical Records
What are you Doing to Correct the Problem;
Interventions, to Resolve the Identified Problem?
Amend a Policy
Re-do Forms
In-Services
An in-service was held for staff and physicians about the importance of
medical record compliance and accurate “timely” completion. The H&P form
was reviewed with Physicians regarding DOS update and specific
documentation.
Another medical record audit will occur in 30 days by the DON.
# 8 Re-Measurement
Medical Records
A second round of data collection and analysis of the problem to determine
objectively whether the corrective actions, i.e., interventions, have achieved
and sustained demonstrable improvement. You may need to repeat this
several times until you have reached your desired goal.
(Initial TBD)
1. Use the data collection process you described in Step 4, modify if necessary
2. Use the new data to perform the analyses you described in Step 5.
3. Repeat Step 6 if you haven’t met your goal –
You may need to re-think your original goal if applicable.
#9 If You Have Not Met Your Goal
Medical Records
If the initial corrective action(s) did not achieve and or sustain the desired
improved performance, implementation of additional corrective actions(s)
and continued re measurement until the problem is resolved or is no longer
relevant.
(Initial TBD)
What are you doing to reach your goal, that is different than your re-measurement?
Policy Change
Counseling
New Forms
Staffing Change
# 10 Communication of Your Findings
Medical Records
How are you communicating the quality improvement activities
with your Governing Body and what recommendations are being
made regarding this study? (Are the findings incorporated into the Center’s
educational activities and minutes)?
The Medical Record Audit study and data collection tool was communicated to the
Governing Body. Sub-standard Medical Record documentation is a risk management
concern; the Governing Body approved the study and it’s continuation until the
anticipated goal is reached.
An Action Plan
If you have a non-measurable subject with evidence of your
identification, implementation and outcome, create an
ACTION PLAN
Booking forms getting lost in fax; new dedicated fax line
Continuous repairs; change vendor
New lock on a door; changed a code
CMS Tags; Deficiencies
 “Review of the QA and Governing Body minutes, the Governing Body did not provide leadership and review
of the QA program”.
 “Review of minutes identified incidents of unusual occurrences had been reported, however no root cause
analysis had been completed on the incidents. No evidence was found of an investigation and no
interventions were put into place to minimize risks for other patients. The action plan indicated, continue to
document".
 “The committee indicated this would be followed up on, however, review of minutes from the next meeting
identified no documentation of the concern identified, no actions were taken or analysis to determine
preventive strategies to promote patient safety”.
CMS Tags; Deficiencies
 “Based on interview, review of personnel files, governing body and medical staff bylaws
and governing body meeting minutes, the ASC did not assure that medical staff privileges
were reappraised every two (2)* years, in accordance with the Governing Body Bylaws
and the Medical staff Bylaws”.
 Findings include: “A review of personnel files lacked any evidence of re-credentialing or
reappraisal of medical staff privileges since initially approved by the Governing Body in
2011”.
*Consider re-credentialing every 36 months.
10 Step Study vs Benchmarking
A 10 Step Study is implemented when A Problem
or Trend has been Identified in your Center.
Benchmarking is done with Specific Data to
Understand where your Center Stands, with
Identifiable Areas of Relevance.
What Can You Benchmark?
Everything and Anything that Occurs Within Your Center
Types of Benchmarking
INTERNAL Looking within your Own Center
EXTERNAL Comparing with Like Center
NATIONAL Comparing with National Center
Internal Benchmarking
• Physician to Physician
• Supply Costs Per Vendor
• Benefits- Salaries
• Hand Hygiene
• Chart Audit
• Compare Last Years Numbers to Current Numbers
External Benchmarking
• Benchmark with other Center’s that are the same Specialty or Size as yours,
Because their Best Practices will be more Likely to Work in your Center
• It’s an Opportunity to Set Realistic Goals for Improving Performance and your
Process
• If an Equal Center can Perform at a Certain Level with Best Practices, then so
can yours! It Allows you to see if you have an Issue (s) in your Center
National Benchmarking
ASC Quality Collaboration www.ascquality.org
ASCA
asc@ascassociation.org
Clinical Examples
Medication Errors
Falls
Transfers
Burns
Infections
Re-Admission to OR
Narcotic Counts
BBP Occurrence
Incorrect Site
Prolonged PACU Stay
Delays
Incomplete Colonoscopy
Physician Late Arrival
Equipment Issues
Turnover Time
Post-Op Complication
History and Physicals
Hand Hygiene
Administrative Examples
Op Reports Outside 30 Days
Medical Record Audits
Total Cases Performed
Case Cancellations/ No-Shows
Peer Review
Employee Injuries
Patient Wait Times
Patient Satisfaction Return Rate
Financial Examples
Case Costing Per Specialty Per Physician
Block Time Utilization
Billing Delays
Coding
AR Days (Per Insurance)
Number Of Cases
Net Revenue
Staffing Costs Per Patient
Overtime Dollars
Samples of Benchmarking Reports
• If you are Familiar with EXCEL or POWERPOINT you can
Transform your Data into an “Attractive” Visual Report
• If you Collect Data Manually, you can Turn it into a Template or
Spreadsheet
• If you use QUICKBOOKS your Financial Data can be
Manipulated into a Report/Graph
Patients Seen Per Quarter 2013
Internal
499
433
345
318 322
400
344
445
Q1
400
350
316 300
Q2
Q3
Q4
Dr. A
Dr. B
Dr. C
Average AR Days Per Insurance Carrier
60
2013
50
40
30
51
2012
44
31
23
20
10
Internal
24
30
45
43
0
Medicare
Cigna
BC/BS
Aetna
Hand Hygiene Monitoring
Internal
May 1, 2013 - May 31, 2013
100
96
80
60
78
89
66
40
20
0
Surgeons
Nurses
Anesthesiologists
Techs
Patient Hospital Transfers
5
5
Internal
5
4
4
3
2013
3
2
2
2
1
1
1
0
Q1
Q2
Q3
Q4
2012
Q2 Patient Survey Return Rates
External
81%
59%
58%
24%
23%
16%
NJ234
NJ121
NJ355
34%
29%
NJ388
13%
NJ790
NJ289
NJ122
NJ277
National
Rate
Calendar of 2014 ASC Studies
Sasso Consulting, LLC
Registration
Fee
Data Collection Period
Name of Benchmark Study
□ $ 150.00
Q1
Jan 1 - March 31
Occurrences
(needlesticks/sharps, PT transfer, fall, visitor injury, re-admit to OR,
equipment failure)
□ $ 150.00
□ $ 150.00
□ $ 150.00
□ $ 150.00
□ $ 150.00
□ $ 150.00
Mini 1
Feb 1 - March 31
Case Costing
□ EGD (w/o biopsy)
Q2
April - June 30
Cancellations
(select one)
(within 48 hours of procedure does not include re-scheduled cases)
Mini 2
May 1 - June 30
Patient Satisfaction Returns
Q3
July 1 - Sept 30
Medical Record Audit (H&P, Pre-Op / PACU Orders, Discharge Order, OP report,
Mini 3
Sept 1 - Oct 31
□ GI Specific
Q4
Oct 1 - Dec 31
Billing
□ Lumbar Epidural
□ Cataract
Data Collection
Due Date
April 15
April 15
July 15
July15
October 15
Medication Reconciliation)
or
□ in network
Amount enclosed $ __________
□ Ophthalmic Specific
(Delays, Claim Denials, AR days)
□ out of network
□ both in and out of network
# Programs ______
Sign up for 4 or more studies and receive a complimentary QA Excel data collection tool ++
Customized Excel templates will be sent via email 2 weeks prior to start of each registered study collection period.
Nov 15
Jan 15, 2015
Websites with Additional Information
ASC Quality Collaboration website
http://ascqua;ity.org/qua;itymeasurers.cfm
Ambulatory Surgery Center Association (ASCA)
www.ascassociation.org
CMS ASC Center
www.cms.gov/center/asc.asp
Quality Net website (CMS Specifications Manual)
www.qualitynet.org
Contact Information
For Additional Information
Marcy Sasso, CASC
marcy@sassoASC.com
(862) 812-5611
Madison, NJ 07940
Thank You for Participating in
“Quality For your Surgical Center”