1. Federal Ambulatory Surgery Center Quality Reporting Program
Florida State Consumer Health Information and Policy Advisory Council
David Shapiro, M.D.

2. Federal Quality Reporting
In November 2001, Health & Human Services’ (HHS) Secretary Tommy G. Thompson announced The Quality Initiative, his commitment to assure quality healthcare for all Americans through published consumer information coupled with healthcare quality improvement support through Medicare’s Quality Improvement Organizations (QIOs).
The Quality Initiative was launched nationally in 2002 as the Nursing Home Quality Initiative (NHQI) and expanded in with the Home Health Quality Initiative (HHQI) and the Hospital Quality Initiative (HQI).
These initiatives are part of a comprehensive look at quality of care that includes hospitals, nursing homes, home health agencies, and physician offices.

3. Federal Quality Reporting
In 2006, the ASC community began encouraging the Centers for Medicare & Medicaid Services (CMS) to establish a uniform quality reporting system that would allow ASCs to publicly demonstrate their performance on quality measures.
CMS implemented the Ambulatory Surgical Center Quality Reporting (ASCQR) Program on October 1, 2012.

4. Quality Measure Reporting
Federal Measurement Development Process: CMS selects measures that reflect consensus among affected parties and, to the extent feasible and practicable, that these measures include measures set forth by one or more national consensus building entities (e.g. NQF). The ASC community formed the ASC Quality Collaboration in 2006 to initiate the process of developing standardized ASC quality measures

5. ASC Quality Collaboration
Efforts on the Regulatory and Legislative fronts
Measure Development process occurs over several years
The measures included in the program have been developed using a multi-step process. Each has been vetted with both our internal panel of technical experts and an external panel of individuals and/or organizations with relevant expertise. All of the measures have been pilot tested in ASCs and assessed for validity, feasibility and reliability.

6. ASC Quality Reporting Program
Often referred to as the ASC QRP
The ASC quality reporting program officially began on October 1, 2012
Data collection began in CY 2012 for certain measures
Applied to the CY 2014 payment determination

7. ASC QRP Overall Structure
ASCs that don’t submit quality measure data incur up to a 2.0% reduction to any annual increase provided under the payment system for the specified year
Several mechanisms of reporting
Staggered implementation of required measures
Annual Review New Measures, Retired Measures
Many unresolved issues remain

8. How Data Is Reported Claims Based Reporting-Quality Data Codes
Web Based Reporting via QualityNet Secure Portal
Web Based Reporting Via Centers for Disease Control and Prevention (CDC) National Health Care Safety Network (NHSN)
Administrative Claims

9. Measurement 101
Measures can be divided into two general categories: Outcome and Process
The measures developed by the ASC QC include both outcome measures and process measures
An outcome measure assesses patients for a specific result of health care intervention.
A process measure evaluates a particular aspect of the care that is delivered to the patient.

10. Measurement 102
Measure Type States whether the measure is an outcome measure or a process measure
Description A brief description of what is measured
Numerator: Patient population experiencing the outcome or process of care being measured.
Denominator: The patient population evaluated.
Inclusions/Exclusions of both Numerator and Denominator
Data Sources The documents that typically contain the information needed to determine the numerator and denominator
Definitions Specific definitions for the terms included in the numerator and denominator statements

11. Patient Burn
This measure is used to assess the number of admissions (patients) that experience a burn prior to discharge
Numerator: Ambulatory Surgery Center ASC admissions experiencing a burn prior to discharge
Denominator: All ASC admissions.
Definition:
Burn: Unintended tissue injury caused by any of the six recognized mechanisms: scalds, contact, fire, chemical, electrical or radiation, (e.g. warming devices, prep solutions, electrosurgical unit or laser).

12. Patient Fall
This measure is used to assess the number of admissions (patients) that experience a fall within the ASC
Numerator: Ambulatory Surgery Center (ASC) admissions experiencing a fall within the confines of the ASC
Denominator: All ASC admissions
Definition:
Fall: a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. (National Center for Patient Safety)

13. Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
Description: This measure is used to assess the number of ASC admissions (patients) experiencing a wrong site, side, patient, procedure or implant
Numerator: All Ambulatory Surgery Center (ASC) admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or wrong implant.
Denominator Inclusions: All ASC admissions
Definitions:
Admission: completion of registration upon entry into the facility.
Wrong: not in accordance with intended site, side, patient, procedure or implant

14. All Cause Hospital Transfer/Admission
Numerator: Ambulatory Surgery Center (ASC) admissions requiring a hospital transfer or hospital admission upon discharge from the ASC.
Denominator: All ASC admissions.
Definitions:
Admission: completion of registration upon entry into the facility.
Hospital transfer/admission: any transfer/admission from an ASC directly to an acute care hospital including hospital emergency room.
Discharge: occurs when the patient leaves the confines of the ASC
While hospital transfers and admissions undoubtedly represent good patient care when necessary, high rates may be an indicator that practice patterns or patient selection guidelines are in need of review.

15. Influenza Vaccination Coverage Among Healthcare Personnel
Numerator: The numerator for this measure consists of HCP in the denominator population, who during the time from when the vaccine became available (for example, August or September) through March 31 of the following year:
received an influenza vaccination administered at the healthcare facility; or
reported in writing (paper or electronic) or provided documentation that influenza vaccination was received elsewhere; or
were determined to have a medical contraindication/condition of severe allergic reaction to eggs or other component(s) of the vaccine, or history of Guillain- Barré Syndrome (GBS) within 6 weeks after a previous influenza vaccination; or
were offered but declined influenza vaccination; or
had an unknown vaccination status or did not otherwise meet any of the definitions of the above-mentioned
The numerator data are mutually exclusive. The sum of the numerator categories should be equal to the denominator for each HCP group.

16. Influenza Vaccination Coverage Among Healthcare Personnel
Denominator: The denominator for this measure consists of HCP who are physically present in the healthcare facility for at least 1 working day between October 1 and March 31 (for example, the measure reporting period) of the following year. Denominators are to be calculated separately for three required categories of HCP and can also be calculated for a fourth optional category:
Employees: This includes all persons who receive a direct paycheck from the reporting facility (for example, on the facility’s payroll), regardless of clinical responsibility or patient contact.
Licensed independent practitioners (LIPs): This includes physicians (MD, DO), advanced practice nurses, and physician assistants who are affiliated with the reporting facility, but are not directly employed by it (for example, they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Post-residency fellows are also included in this category if they are not on the facility’s payroll.
Adult students/trainees and volunteers: This includes medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older who are affiliated with the healthcare facility, but are not directly employed by it (for example, they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.
Other contract personnel (optional): Facilities may also report on individuals who are contract personnel. However, reporting for this category is optional at this time. Contract personnel are defined as persons providing care, treatment, or services at the facility through a contract who do not fall into any of the above-mentioned denominator categories.

17. Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients
Description: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report
Numerator Statement: Patients who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report
Denominator Statement: All patients aged 50 to 75 years of age receiving screening colonoscopy without biopsy or polypectomy

18. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
Description: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp(s) in previous colonoscopy findings, who had a follow-up interval of 3 or more years since their last colonoscopy
Numerator Statement: Patients who had an interval of 3 or more years since their last colonoscopy
Denominator Statement: All patients aged 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp(s) in previous colonoscopy findings

19. Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
Description: Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery
Numerator Statement: Patients who had improvement in visual function achieved within 90 days following cataract surgery, based on completing both a pre- operative and post-operative visual function instrument
Denominator Statement: All patients aged 18 years and older who had cataract surgery and completed both a pre-operative and post-operative visual function instrument
Voluntary

20. Normothermia
Description: This measure is used to assess the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within 15 minutes of arrival in PACU.
Numerator: Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU
Denominator: All patients, regardless of age, undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes duration

21. Unplanned Anterior Vitrectomy
Description: This measure is used to assess the percentage of cataract surgery patients who have an unplanned anterior vitrectomy.
Numerator: All cataract surgery patients who had an unplanned anterior vitrectomy
Denominator: All cataract surgery patients

22. Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Description: The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy among Medicare Fee-for-Service (FFS) patients aged 65 years and older.
Rationale: This measure will reduce adverse patient outcomes associated with preparation for colonoscopy, the procedure itself, and follow-up care by capturing and making more visible to providers and patients all unplanned hospital visits following the procedure. The measure score will assess quality and inform quality improvment

23. Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Numerator Statement:
This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged years receiving one or more hemoglobin A1c tests per year); thus, we are using this field to define the outcome. The calculation of the rate is defined below under Measure Calculation.
The outcome for this measure is all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy. The measure defines a hospital visit as any emergency department (ED) visit, observation stay, or unplanned inpatient admission.
Denominator Statement:
The target population for this measure includes low-risk colonoscopies performed in the outpatient setting for Medicare FFS patients aged 65 years and older. For implementation in the ASCQR Program, the measure will be calculated among ambulatory surgical centers (ASCs).

24. Recent Developments Participation
Almost all — 96.9 percent — of Medicare-certified ASCs met the requirements and will receive full payment for the calendar year.
The following measures reported data all reflected better results in 2016 than the previous year:
Patient burn Patient fall Wrong site, side, patient procedure, implant Hospital all cause transfer/admission Prophylactic intravenous antibiotic timing Safe surgery checklist use

25. Recent Developments Measures removed from ASC QRP in 2018:
Safe Surgery Checklist Use
Prophylactic Intravenous Antibiotic Aiming
ASC Facility Volume Data on Selected ASC Surgical Procedures

26. Future Measures Scheduled for the ASC QRP
Hospital Visit after Orthopedic Ambulatory Procedures
Hospital Visit After Urology Ambulatory Surgery Procedures
The measures are all-cause, unplanned hospital visits (Emergency Department, Observation Stays, Unplanned Inpatient Admission) within 7 days of a procedure in of either categorization
No data submission or reporting from the ASC is required
Data will be pulled by CMS from the Medicare Fee For Service Administrative Claims during the CY (January 1, 2020-December 31, 2020)

27. Possible Future Measures Presently Under Development
Surgical Site Infection After Breast Procedure In An Ambulatory Surgery Center (ASC)
Unplanned Hospital Visits Within 7 Days After Selected General Surgery Procedures In An Ambulatory Surgical Center (ASC)

28. OAS CAHPS
Five measures are based on the use of the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS). They are:
ASC-15a: OAS CAHPS – About Facilities and Staff;
ASC- 15b: OAS CAHPS – Communication About Procedure;
ASC-15c: OAS CAHPS – Preparation for Discharge and Recovery;
ASC-15d: OAS CAHPS – Overall Rating of Facility
ASC-15e: OAS CAHPS – Recommendation of Facility

29. OAS CAHPS Standardized administration protocols Approved methodologies
Mail only
Two waves-
First: no later than 3 weeks after close of sample month.
Subsequently: approximately 3 weeks later to non respondents
Telephone only
Start no later than 3 weeks after close of sample month
Completed within 6 weeks
No more than 5 attempts
Mixed Mode- Mail survey with telephone follow up
Complete within 6 weeks

30. OAS CAHPS 37 Questions in Length
Required minimum of 300 completed surveys within 12 month period
If unable to obtain 300, ASC will need to survey all patients
Must use CMS approved vendor
List of approved vendors on OAS Chaps website
Voluntary implementation at present
Mandatory implementation date now uncertain

31. Federal Ambulatory Surgery Center Quality Reporting Program
Florida State Consumer Health Information and Policy Advisory Council
David Shapiro, M.D.