Governing Body QAPI 2013 Update for ASC California Department of Public Health

2013 Update Many facilities now being re-surveyed on the CMS 3 year schedule Pleased to report that a significant number of those facilities have demonstrated marked improvement and compliance Reviewed Policies & Procedures have been updated and corrected

2013 Update An ASC by any other name is still a surgical facility, first and foremost This means the facility must meet all applicable State and Federal regulations concerning operating room environments

Governing Body

Governing Body The ASC must have a GB that assumes full legal responsibility for determining, implementing, and monitoring policies governing the ASC’s total operation. The GB has oversight and accountability for the quality assessment and performance improvement program (QAPI)

Governing Body Policies must be effective and compliant GB responsibilities are closely tied to the requirements under Medical Staff, QAPI, and Patient Rights CMS is stressing in the new regulations that the GB is completely responsible for the QAPI program and its implementation

Governing Body Specific responsibilities include: Adopting formal P&P that govern all operations within the ASC Direct oversight and accountability for the QAPI program Ensure the overall quality of the ASC’s healthcare services Ensure a safe environment for all care Develop & maintain a disaster preparedness plan

Governing Body The GB may delegate certain day-to-day operational responsibilities To administrative, medical, and support personnel Must retain overall responsibility Delegations must be documented in writing

Governing Body Important to recognize that deficiencies noted under the QAPI tag may well result in citation under the GB tags as well Similar situation for “safe environment”

Governing Body When services are provided through a contract with an outside resource, the ASC must assure that these services are provided in a safe and effective manner. GB oversight includes following the performance of these contracts under the QAPI program

Governing Body The ASC must have an effective procedure for the immediate transfer to a hospital of patients requiring emergency medical care beyond the capabilities of the ASC

Governing Body The ASC must: Have a written transfer agreement with that hospital Ensure that all physicians performing surgery at the ASC have admitting privileges at an available hospital Stabilize and provide emergency care for a patient awaiting such transportation Take necessary steps to arrange admission for patient to hospital

Governing Body The ASC must maintain a written disaster preparedness plan which provides for the emergency care of patients, staff, and others in the facility, in the event of fire, natural disaster, or other unexpected events or circumstances that are likely to threaten the health and safety of those in the ASC

Governing Body The ASC should conduct at least yearly disaster drills to test the plan’s effectiveness The ASC should maintain a written evaluation of each drill and promptly correct any corrections needed

QAPI

QAPI The ASC must develop, implement, and maintain an ongoing, data-driven quality assessment and performance improvement (QAPI) program.

QAPI QAPI must include an ongoing program that demonstrates measurable improvement in patient health outcomes, as well as uses quality indicators or performance measures associated with improved health outcomes and reduction of medical errors. Focus on process rather than specific issues

QAPI The program must measure, analyze, and track quality indicators, adverse patient events, infection control, and other aspects of performance covering care and services furnished in the ASC

QAPI Types and Examples of Quality Indicators Outcomes: results of care, HAI rates, complications, hospital transfers and cases requiring over 24 hours of care Process of care: checking on how often well-defined processes such as antibiotic prophylaxis before surgery are carried out Patient perceptions of care received

QAPI ASC’s performance improvement activities must focus on areas with most impact: High risk areas High volume procedures Problem-prone areas Consider the following 3 areas: Incidence Prevalence Severity

QAPI Examples of quality indicators include: Patient burns Patient falls Hospital transfers Wrong site surgeries Use of prophylactic IV antibiotics and timing in relation to the procedure

QAPI ASCs must: Identify and reduce medical errors Failure of planned action to be completed as intended, or using a wrong plan to achieve an aim Measure and analyze adverse patient events Errors don’t necessarily have to result in patient harm Adverse event which is due to an error is “preventable”

QAPI Some examples of adverse events are: Patient burns due to surgical fire Transfer to an acute care facility Patient fall Wrong site or procedure Retained instruments or sponges Surgical site infection

QAPI ASC must track all adverse patient events to determine: Whether they were due to an error and could be preventable How to reduce the likelihood of recurrence

QAPI Based upon that analysis, ASC must implement corrective actions which are likely to reduce medical errors and adverse patient events Must monitor the corrective actions to see if improvement occurs

QAPI Each ASC must undertake performance improvement projects each year: Activities should correlate to issues or problems identified Must document showing: Why project was chosen What data was collected and why What evidence that project will lead to improvement (i.e. a national standard) Show current status of project

QAPI The Governing Body is responsible to ensure that the QAPI program: Is defined, implemented, and maintained Specifies data collection methods, frequency, and details Evaluate all improvements for effectiveness Clearly establish expectations for safety Have enough staff, time, and information systems, as well as training, to implement the QAPI program