“ quality program for surgery centers
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“Quality Program for
Surgery CentersMarcy 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 FormPre-op Phone CallPatient RegistrationPre-op AssessmentConsentsMedical Record DocumentationTime- OutRecoveryTo 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 ExamplesContracts
Preventative MaintenancePatient Satisfaction Chart AuditsPeer Review
CredentialingMinutes * Quarterly
MeetingsEducation In-
Services*Document all QA Activity
Drills, Safety & RoundsMalignant Hyperthermia- General Anesthesia AnnuallyFire, With Scenario, And Transmission FormQuarterlyDisaster, With Scenario
Every 6 monthsCode Blue
Annually
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 BurnPatient Fall Appropriate Hair RemovalHospital Transfer / Admission Prophylactic Antibiotic TimingWrong 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 VolunteersLicensed 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 TimesA dialog Needs to Occur, to Effectively Decide on what Needs to be Studied and Possibly Revised
Ten Step Template Medical Records
1. Purpose2. Identification of the performance goal3. Description of the data that will be collected4. Evidence of Data Collection (not the conclusion) 5. Data analysis that describes the findings6. 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 relevant10. 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 FallsTransfers BurnsInfections Re-Admission to ORNarcotic Counts BBP OccurrenceIncorrect Site Prolonged PACU StayDelays Incomplete ColonoscopyPhysician Late Arrival Equipment IssuesTurnover Time Post-Op ComplicationHistory and Physicals Hand Hygiene
Administrative Examples
Op Reports Outside 30 DaysMedical Record AuditsTotal Cases PerformedCase Cancellations/ No-ShowsPeer ReviewEmployee InjuriesPatient Wait TimesPatient Satisfaction Return Rate
Financial Examples
Case Costing Per Specialty Per PhysicianBlock Time UtilizationBilling DelaysCodingAR Days (Per Insurance) Number Of CasesNet RevenueStaffing Costs Per PatientOvertime 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
2331
4451
24 3045 43
2013
Hand Hygiene Monitoring Internal
Surgeons Nurses Anesthesiologists Techs0
20406080
100
7896
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 InformationMarcy Sasso, CASC
marcy@sassoASC.com(862) 812-5611
Madison, NJ 07940
Thank You for Participating in “Quality For your Surgical Center”
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