1. “Quality Program for
Surgery Centers
Marcy Sasso, CASC

2. 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

3. Quality Program- It’s a Name
Quality Assurance QA
Quality Improvement QI
Performance Improvement PI
Quality Assurance Performance Improvement QAPI
Total Quality Management TQM

4. 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

5. 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

6. Continual Quality Examples
Contracts Preventative Maintenance
Patient Satisfaction Chart Audits
Peer Review Credentialing
Minutes * Quarterly Meetings
Education In-Services
*Document all QA Activity

7. 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

8. Why Have a Quality Program Anyway?
It’s REQUIRED for CENTER ACCREDIDATION TJC AAAHC AAAASF Medicare- CMS To PROVIDE QUALITY PATIENT CARE

9. CMS Regulations Q
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 (d)(1) Every ASC must undertake one or more specific quality improvement projects each year * (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.

10. 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

11. 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

12. Selected Procedures Procedure Category Corresponding HCPCS Codes:
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 (

13. 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

14. ASC 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

15. 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

16. Ten Step Template Medical Records
Purpose
Identification of the performance goal
Description of the data that will be collected
Evidence of Data Collection (not the conclusion)
Data analysis that describes the findings
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.
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.
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
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 ______________

17. # 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.

18. # 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

19. # 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

20. # 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

21. # 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.

22. # 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?

23. # 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.

24. # 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.

25. #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

26. # 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.

27. 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

28. 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”.

29. 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.

30. 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.

31. What Can You Benchmark?
Everything and Anything that Occurs Within Your Center

32. Types of Benchmarking INTERNAL Looking within your Own Center
EXTERNAL Comparing with Like Center
NATIONAL Comparing with National Center

33. Internal Benchmarking
Physician to Physician
Supply Costs Per Vendor
Benefits- Salaries
Hand Hygiene
Chart Audit
Compare Last Years Numbers to Current Numbers

34. 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

35. National Benchmarking ASC Quality Collaboration www. ascquality
National Benchmarking ASC Quality Collaboration ASCA

36. 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

37. 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
Cancellations, you have the most control over
Why are cancellations occurring, is it the same physician or group
If you are receiving less than 30% patient satisfaction returns, look at your process

38. 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
Are staff doing pre-certification on all patients
Are claims going out clean
Are some physicians using the top of the line supplies
Is the block time to loose
Why are OT dollars occurring, do you use per diem

39. 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

40. Patients Seen Per Quarter 2013 Internal

41. Average AR Days Per Insurance Carrier Internal

42. Hand Hygiene Monitoring Internal

43. Patient Hospital Transfers Internal

44. Q2 Patient Survey Return Rates External

45. Calendar of 2014 ASC Studies Sasso Consulting, LLC

46. Websites with Additional Information
ASC Quality Collaboration website
Ambulatory Surgery Center Association (ASCA)
CMS ASC Center
Quality Net website (CMS Specifications Manual)

47. For Additional Information
Contact Information
For Additional Information
Marcy Sasso, CASC
(862)
Madison, NJ 07940

48. Thank You for Participating in “Quality For your Surgical Center”