QAPI: THE FUTURE OF REPORTING QUALITY CARE TO THE DIFFERENT
AGENCIES THAT GOVERN OUR PRACTICE
Beverly Kirchner, RN, BSN, CNOR, CASCSeptember 2010
Objectives
1) Discuss the new standards on quality reporting for CMS in a surgery center
2) Discuss the ASC Quality Collaboration work completed and approved by NQF for surgery centers.
3) Describe a QAPI plan that meets the accrediting bodies requirements.
4) Describe the future of quality care and reporting.
Brief Overview of Agencies that Govern ASC’s
CMS State OSHA CDC NFPA NQF Accrediting Organizations
416.41 Governing Body and Management
Must have Governing Body Assumes full legal responsibility for operation of
center Oversight & accountability
Quality Assessment Performance Improvement
Ensures polices & programs are followed Ensures the center provides quality care in a
safe environment
416.41 Governing Body and Management Continued
Oversees contracted services Transfer agreement
Written Hospital CMS Certified
Assures all physicians & allied health staff have: Education Privileges Peer Review Utilization review
Assures physicians have admitting privileges at a hospital that is CMS certified
416.41 Governing Body and Management Continued
Disaster Plan Addresses care for patient & staff Addresses any event that could threaten the
health and safety of anyone in the center Coordinates plan with state & local authorities Conducts drills at least annually
Governance Organizational Chart
Medical Executive Committee
BOARD
Administrator
Business Office
Manager
Director of Nurses
Committee Organizational Chart
BOARD
MEC
Administrator
QAPI Committee
Safety Officer
Infection
Control
Pharmacy Employee Health
Nursing Care
Committee
Radiation Safety
416.42 Quality Assessment & Performance Improvement
Develop Implement Maintain ongoing program Data driven Demonstrates measurable improvement
416.42 Quality Assessment & Performance Improvement Continued
Center Must Measure Analyze Track quality indicators Adverse patient events Infection Control Data must be used to monitor effectiveness & safety of
services provided Identify opportunities for improvement Focus on high risk, high volume, problem-prone areas Number of scope projects conducted annually must
reflect complexity of ASC’s services
416.42 Quality Assessment & Performance Improvement Continued
Documentation Reason Description Specifies data collection method, frequency &
details Center must allow sufficient staff
Time Information Systems Training & education
ASC Quality Collaboration
ASC Quality Collaboration Formed in 2006 Focus: on healthcare quality & safety
Today’s Focus Measure development Public Reporting of Quality Data Advancing ASC Quality Advocacy
National Quality Forum Endorsed Measures
Patient Fall Patient Burn Hospital Transfer/Admission Wrong Site, Side, Patient Procedure, Implant Prophyloctic IV Antibiotic Timing Appropriate Surgical Site Hair Removal
The ASC Quality Collaboration is dedicated to advancing
high quality, patient-centered care in ambulatory surgery
centers.
How are we doing?
Rate of patient fall in the ASC 0.149 per 1000 admission
Represents the experience of 1,278,879 ASC admissions seen 1,130 facilities between January 1 and March 31, 2010
Rate of Patient Burns: 0.037 per 1000 Admission
Represents the experience of 1,275,578, ASC admissions seen in 1,123 facilities between January 1 and March 31, 2010.
Rate of Hospital/Admissions: 1.081 per 1000 admissions
Represents the experience of 1,334,614 ASC admissions seen in 1,185 facilities between January 1 and March 31, 2010.
Wrong Site, Side, Patient, Implant events: 0.034 per 1000 admissions
Represents the experience of 1,308,530 ASC admissions seen in 1,169 facilities between January 1 and March 31, 2010.
Percentage of ASC admissions with Antibiotics ordered who received antibiotics on time: 95%
Represents the experience of 692,129 ASC admissions seen in 674 facilities between January 1 and March 31, 2010.
ASC Tools for Infection Prevention
Hand Hygiene Safe Injection Practice Point of Care Devices
Future Tool Kit Environment of Care
Website: ASC Quality.org Last accessed: August 23,2010
Elements of an ASC QAPI Plan
Mission Statement components: Direct activities concerning design of new services Monitor processes Assess processes Measure quality of care
Patient satisfaction Peer review Service Patient outcomes
Look for opportunities to improve
Elements of an ASC QAPI Plan
Program Plan components: Discuss ongoing process Discuss responsibility of Board Discuss responsibility of Committee Discuss reporting system in the facility
Purpose: To provide service excellence, and the improvement of patient outcomes and processes by acting on opportunities for increment performance improvement.
Elements of an ASC QAPI Plan
Leadership Responsibilities: Set expectations Manage processes Set priorities to measure Improve the quality of:
Governance /Education Management/ Education Clinical care/ Education Patient care Support activities
Safety Risk management Infection prevention
Elements of an ASC QAPI Plan
Design of approach to improving process Design of processes Provide resources Implementation of performance processes Follow-up on performance processes
Assess if there is improvement How effective is the improvement
Quality Assessment: Performance Improvement Committee
Members include: Chair Anesthesia provider Surgeon Center administrator or clinical coordinator Staff members
OR Admission PACU Infection Preventionist Safety Officer Risk Manager Business office
Quality Assessment Performance Improvement Committee Responsibilities:
Review Process deficiencies Problems Failures User error
Select and prioritize improvement opportunities Identify resource needed for a project Request resources from the Governing Board through
Leadership team Create PI project design
Complete an assessment of potential problem Research issue Develop goals Design tool for data collection
Quality Assessment Performance Improvement Committee Responsibilities Continued:
Determine expected outcome to measure Implement change
Obtain Governing Board approval Educate staff
Reporting results
The Chair of the Quality Assessment Improvement Committee is
responsible for providing program support to the staff and leadership.
Quality Assessment Performance Improvement Committee’s work and reports
are ongoing.
Establish a calendar for meetings Establish a schedule/agenda on what is
reported at each meeting Prepare a quarterly report of all activities to be
presented to the Medical Executive Committee and Governing Board
QAPI documents are kept confidential
Example of QAPI Meeting Calendar
Month Aspect of Care/Service
Responsible Reporter
Appropriateness of Care/Benchmarks
Administrator
JANUARY Occurrence/Variance Reports for opportunities for process improvement
Administrator
Risk Management Report Risk Manager or Administrator
Environment of Care-Safety Safety Officer
Medication Process Pharmacy Nurse & Pharmacy Consultant
FEBRUARY Clinical Process Clinical Coordinator or Administrator
Business Office Process Business Office Manager or Designee
Infection Prevention Infection Preventionist
MARCH Employee Health Employee Health Nurse
Patient Satisfaction Administrator
Other projects Chair QAPI
QAPI Committee Reports Organization Wide to
Annual Medical Staff Meeting Quarterly Medical Executive Committee Quarterly to the Governing Board Monthly at Staff Meeting
QAPI Committee Reports outside of Committee meeting do not include the Names of patient, provider, or employee
Only QAPI Committee Members are given identifying information. Only committee members can attend meeting.
Successful QAPI Programs
Encourage staff participation & support program
Encourage medical staff participation & support program
Provide easy ways to make suggestions or communicate process problems identified
Medical Executive Committee and Governing Board support the program
Leadership supports the program
Developing a Performance Improvement Program/Project
Resources Budget dollars for resources needed Obtain approval Governing Board
Program Program/Project selection should be important to the
organization Doing the right thing Doing the right thing well
Patient & Organization Focused Patient or organizational rights Patient assessment Patient rights Educational Continuity of care Improving organization performance
Developing a Performance Improvement Program/Project Continued
Improve Leadership Manage Environment Manage Human Resources Manage Information Prevention Safety
Program Should Reflect
Organizational Mission and Vision Be collaborative with different services Support for organization Meet the needs of the organization
Program/ Project Should Identify
Dimensions of performance that will be most affected
Improved performance goal or goals How the team will determine if new process is
performing the way the team anticipated Who will work on the program/project
Program/Project Data Collection & Performance
Focus on process or outcome Provide base data Identify opportunity for improvement Create process redesign Collect data –ongoing Re-evaluate –make changes if needed
Program/Project Assessment
Compare past performance with standards, policy, Best Practices
Monitoring is ongoing Focus intense assessment on:
Major discrepancies between pre & post-op Confirm medication, transfusions or any other
unexpected reactions Review all medication errors Any unexpected event or outcome
Quality Assessment Performance Improvement Committee will
oversee the review and revision of the center’s policies and procedures annually.
Unplanned Hypothermic Event
Name of Measure Unplanned Hypothermic Event
Measure Type OutcomeIntent To capture the number of admissions (patients) who receive a preadmission
assessment for risk of hypothermic event during invasive procedure and have approved interventions utlized to prevent an unplanned hypothermic event and still experiences a hypothermic event.
Numerator/Denominator Numerator: Ambulatory Surgery Center (ASC) admissions experiencing an unplanned hypothermic event detected by temperature monitoring throughout patient stay.Denominator: All ASC admissions who have a procedure performed.
Inclusions/Exclusions Numerator: Ambulatory Surgery Center (ASC) admissions experiencing an unplanned hypothermic event detected by temperature monitoring throughout patient stay.Numerator Exclusions: NoneDenominator Inclusions: All ASC admissions who have a procedure performed.
Denominator Exclusions: Admissions who upon being admitted to the ASC are experiencing a hypothermic event.
Data Sources ASC operational data including but not limited to adminsitrative records, medical records, and follow up, all quality management data related to the patient's unplanned hypothermic event and post op calls from patients or physician offices.
Definitions Admission: completion of registration upon entry into the facility; Allowable values: The count for this data element would be represented by any whole number 0 or greaterUnintended hypothermia: any core temperature below 36 degree C or 96.8 degrees F . Inadvertent hypothermia: any core temperature less than 36 degrees C or 96.8 degrees FDischarge: occurs when the patient leaves the confines of the ASC
Monitoring Unplanned Hypothermia Events
Quality Assurance Project
Purpose: To develop a standardized process in which unplanned hypothermic events occur in
less than five (5) percent of patients undergoing an invasive procedure in the center.
Background/Significance•It is estimated that 50% to 90% of patients undergoing a surgical procedure will experience a hypothermic event. •An unplanned hypothermic event is preventable. •Hypothermia is defined as a core temperature below 36°C (96.8 °F) •Vasoconstriction occurs during a hypothermic event •Vasoconstriction:
-Reduces flow of nutrients to the body -Decreases oxygen delivery
-Inadvently alters wound healing - neurophils / (white blood cells) can't function at optimum
levels
•Perioperative challenges that effect normothermia in a patient:- low ambient room temperatures - patients admission anxiety level- irrigation fluid - IV fluid - Size of skin exposure to room temperature - Prep solutions - Length of surgery - Blood and fluid loss - Anesthesia/anesthesia gases
•Patients at risk for unplanned hypothermic event include:- neonates -older adults
-females -fluid shifts in patient-peripheral vascular disease-cardiovascular disease-endocrine disorders -open wounds -Renal disease •Unplanned hypothermic events affect body systems -Respiratory -Cardiovascular -Adrenergic and immune systems -Alter medication metabolism-Variations in electrolyte levels
•General and regional anesthesia affect core body temperature •Affected ways to decrease risk of an unplanned hypothermia event:
-maintain admission temperature -adequate pain control -hydration-increase ambient room temperature -provide warm blankets-provide warm IV fluid -provide warm Irrigation fluid -humidified and warm anesthesia gases -forced air warming
Tracking Design: Typical Descriptive Study
Phenomenon of Interest Measurement Descriptive Interpretation Hypothesis
Prevention of Unplanned Hypothermia Event Audit Tool Interactive Care Plan & Clinical Pathway 95% Compliance
Method: PDCA Method -Problem: Interventions for unplanned hypothermia are not followed on every patient.-Opportunity: Improve communication (verbal & written) between pre-admission nurse and admission nurseImprove patient satisfaction by
-Educate staff the affects of hypothermia on the patients outcome
-Review on organizational policy
- Review organizational interventions
Patient Flow for Prevention of Unplanned Hypothermia
Patient is scheduled
For SurgeryPreadmission nurse
completes pre-admission nursing
assessment.
Preadmission Nurse plan to patient’s
meddevelops patient care plan and attaches
ical records. Admission nurse further
assesses patient by taking vital signs and initiates interventions
for preventing unplanned hypothermia based on risk analysis.
Admission nurse performs patient care hand off to operating
room circulator.
OR Circulator communicates to OR Team during 1st time
out the risk the patient has for unplanned
hypothermia event and interventions started
based on clinical Pathway and Care Plan.
OR Circulator adds protocols and
interventions the surgeon and or
anesthesia provider request.
OR Circulator and anesthesia provider
performs patient care hand-off with PACU Nurse. PACU Nurse
measures temperature. If patient is hypothermic surgeon and anesthesia provider are notified.
PACU nurse performs patient care hand-off with Discharge nurse
following center policy.
Discharge nurse re-enforces post-op
education to patient and patient's care giver.
Patient care hand-off is performed between
discharge nurse and care giver.
Post-op follow up is completed by center's
staff.
Preadmission Nurse develops patient care plan and attaches plan
to patient’s medical records.
Method: PDCA Model DO
-Develop tracking tool unplanned hypothermic events
-Review data from chart -Review data from chart-Review data from unplanned hypothermic QA
worksheet -Review interventions for effectives -Review findings with: QAPI Committee, Infection
Preventionist, Staff, Leadership Team, Medical Executive Committee, and Board
Unplanned Hypothermia Audit Tool Unplanned Hypothermia includes up-to-date information regarding patient's history, risk level for unplanned hypothermic event, condition, care and interventions.To be completed if patient experiences an unplanned hypothermic event
MR# Did Pre-Admission assessment identify risk for unplanned
hypothermic event?
Were appropriate interventions
accomplished?
Initial Core Temperature
Core Temperature Unplanned
Hypothermic event was noticed
Length of time to get temp back to normothermic
Risk level of Patient
Comments
Yes No N/A Yes No N/A
Method: PDCA Model Check
-Audit medical record of every patient in extreme age groups to assess risk analysis
-Use Audit tool to record unplanned hypothermia events
-Asses staff’s level of understanding of process
-Assess staff’s compliance with policy -Assess staff’s understanding of risk
associated with
Impact Expected
- Supports a culture of safety- Ongoing monitoring is in place to identify
patient risk for unplanned hypothermic- Increase staff understanding of the
dangers to the patient associated with unplanned hypothermia
- Increase staff competency - Increase patient satisfaction
Dissemination of Results to
- Staff - QAPI Committee- Leadership Team - Medical Executive Committee - Board
The Patient Protection & Affordable Care Act Signed in the spring by President Obama Requires
CMS to work with stackholders in the ASC industry and develop a value based purchasing (VBP) System.
Where is ASC Industry Wanting to take Quality Assessment Performance Improvement
1) In favor of developing a value-based purchasing system.
2) Voluntary data collection should start and be followed with public disclosure of quality information.
3) Performance should be measured first within ASC using quality indicators
4)CMS should measure same quality indicators in free-standing surgery centers and hospital out patient departments so the public has apples to apples comparison.
5) Increased Medicare payments should be associated with high performing centers in which there is significant quality
6) Recommend CMS do a share savings plan with centers who perform high quality care and produce savings for Medicare program.
7) Support a program that created competition based on quality and efficiency, drive improvement in care, and improves transparency.
References
Department Health & Human Services, Centers for Medicare and Medicaid Services, State Operations Manual, Appendix L- Guidance for Surveyors: Ambulatory Surgery Centers.
AORN Recommended Practices ASC Quality Collaboration: ASC Quality.org Outpatient Surgery.net> August 2010> ASC
Industry urges CMS to Base Payments on Last accessed 8-24-2010
References
1. Mahoney CB. The economics of patient warning. Outpatient Surgery. 2005: (6) :55-60.
2. Recommended practices for prevention of unplanned perioperative hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 201:293-306
3. Peterson C, ed. Peroperative Nursing Date Set Rev 3rd ed. Denver, CO: AORN, Inc; 2010.
4. Clinical Practice guideline 1 Clinical Guideline for Prevention of Unplanned Perioperative Hypothermia. In:2008-2010 Standards of Perianesthesia Nursing Practice. Cherry Hill, NJ: ASPAN; 2008-2010:22-29