“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

ContractsPreventative Maintenance

Patient Satisfaction Chart Audits

Peer ReviewCredentialing

Minutes * Quarterly Meetings

Education In-Services

*Document all QA Activity

Drills, Safety & Rounds

Malignant Hyperthermia- General Anesthesia Annually

Fire, With Scenario, And Transmission FormQuarterly

Disaster, With ScenarioEvery 6 months

Code BlueAnnually

Fire Extinguishers, Eye Wash, Facility Rounds

Why Have a Quality Program Anyway?

It’s REQUIRED for CENTER ACCREDIDATION

TJCAAAHCAAAASF

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 checklistMay 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 roomApplies to all ASCs, including GI endoscopy centers

Measurement from January 1, 2012 through December 31, 2012Web 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 TeamWhat 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 ImpactDuring 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 necessary2. 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 PLANBooking forms getting lost in fax; new dedicated fax lineContinuous repairs; change vendorNew 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 BenchmarkingASC 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

Dr. A Dr. B Dr. C

345

433 400

318

499

350322

400

316344

445

300

Q1

Q2

Q3

Q4

Average AR Days Per Insurance Carrier Internal

Medicare Cigna BC/BS Aetna0

10

20

30

40

50

60

23

31

44

51

24 3045 43

2013

Hand Hygiene Monitoring Internal

Surgeons Nurses Anesthesiologists Techs0

20

40

60

80

100

78

96

66

89

May 1, 2013 - May 31, 2013

Patient Hospital Transfers Internal

Q1 Q2 Q3 Q40

1

2

3

4

5 5

3

5

22

1 1

42013

2012

Q2 Patient Survey Return Rates External

NJ234 NJ121 NJ355 NJ388 NJ790 NJ289 NJ122 NJ277 National Rate

23%

59%

24%16%

29%

13%

81%

58%

34%

Calendar of 2014 ASC StudiesSasso Consulting, LLC

Registration

Fee Data Collection Period Name of Benchmark Study Data Collection

Due Date

□ $ 150.00 Q 1 Jan 1 - March 31

Occurrences (needlesticks/sharps, PT transfer, fall, visitor injury, re-admit to OR, equipment failure)

April 15

□ $ 150.00 Mini 1 Feb 1 - March 31

Case Costing □ EGD (w/o biopsy) □ Lumbar Epidural □ Cataract (select one)

April 15

□ $ 150.00 Q 2 April - June 30

Cancellations (within 48 hours of procedure does not include re-scheduled cases) July 15

□ $ 150.00 Mini 2 May 1 - June 30

Patient Satisfaction Returns July15

□ $ 150.00 Q 3 July 1 - Sept 30

Medical Record Audit (H&P, Pre-Op / PACU Orders, Discharge Order, OP report, Medication Reconciliation)

October 15

□ $ 150.00 Mini 3 Sept 1 - Oct 31

□ GI Specific or □ Ophthalmic Specific Nov 15

□ $ 150.00 Q 4 Oct 1 - Dec 31

Billing (Delays, Claim Denials, AR days) □ in network □ out of network □ both in and out of network

Jan 15, 2015

Amount enclosed $ __________ # 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.

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 Centerwww.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”