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

2. 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

3. 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

4. Governing Body

5. 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)

6. 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

7. 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

8. 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

9. 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”

10. 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

11. 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

12. 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

13. 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

14. 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

15. QAPI

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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”

23. 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

24. 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

25. 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

26. 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

27. 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