Quality Assurance Ten Step Studies “Survey Tags” Quality Assurance Ten Step Studies Marcy Sasso, CASC

The Objective of this Presentation is to Describe: Examples of Survey Tags/Deficiencies Writing a meaningful a 10 Step Quality Assurance (QA) Study, based on a Survey Deficiency.

10 Step Study A 10 Step Study is implemented when A Problem or Trend has been Identified in your Center. Audit Survey

Most Common Tags §416.51(a) Standard: Sanitary Environment The ambulatory surgery center (ASC) must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice. Surgical masks hanging around the necks and entering OR for a procedure using the same mask; Instructions for Use (IFU) missing or not being followed appropriately Laryngoscope Blades outside of clean packaging; Opening medication vial and not disinfecting the rubber septum prior to piercing with needle with a new alcohol wipe; Improper Hand Hygiene

Ten Step Template Purpose Identification of the performance goal Description of the data that will be collected Evidence of Data Collection (not the conclusion) Data analysis that describes the findings 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. 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. 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 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.

Q 180 416.48 PHARMACEUTICAL SERVICES The ASC must provide drugs and biologicals in a safe and effective manner, in accordance with accepted professional practice, and under the direction of an individual designated responsible for pharmaceutical services.

# 1 Purpose Labeling Syringes Why Is It Important For The Center To Address This Problem Describe The Suspected Problem Or Concern; During a CMS survey the lack of full compliance by some of our Anesthesia providers of safe injection practices per Center policy was observed, and a and IJ was issued and a POC was written.

# 2 Identification of the Performance Goal Labeling Syringes Where Do We Want To Be? Expected Outcome/Goal: Anesthesia providers will follow Center policies and procedures, which are in accordance with Safe Medication Practice guidelines, with a compliance goal of 100%. Actual Outcome: First Round had an overall compliance of 77%

# 3 Description of the Data that will be Collected Labeling Syringes Direct observation by the DON, of the Center Anesthesia providers during random selection of procedures throughout the month of August. An observation Audit Tool will be used for documentation.

# 4 Evidence of Data Collection Labeling Syringes (See Attached form) An observation audit was conducted in August, resulting in a random selection of 88 procedures; of 3 Anesthesiologists and 2 CRNA providers.

# 5 Data Analysis Labeling Syringes Describes the findings, Frequency or Severity of the Problem, how often is it Occurring and Identify the Source of the Problem. Syringes are being labeled correctly 86%of the time, Items on the label are inconsistently being completed: label contains initials of person drawing up meds (45%), medication name (82%), medication strength (82%), and an expiration date/time (45%). Severity: This can lead to miscommunication and patient safety issues regarding safe patient care.

# 6 A Comparison of the Center’s Current Performance Labeling Syringes Analyze Your Data Is there an Increase or Decrease ,where? Do you Note a Trend? The goal of 100% compliance with all standards was NOT met regarding labeling of the syringes.

# 7 Implementation of the Corrective Actions Labeling Syringes What are you Doing to Correct the Problem; Interventions, to Resolve the Identified Problem? The DON met with Anesthesia providers several times to review the standards of Safe Injection Practices Policy; to include the elements of labeling, and re-educated the Anesthesia providers to ensure compliance with the standards. The education included a reviewing the “Medication policy”, and the CMS ASC Infection Control Surveyor Worksheet.

# 8 Re-Measurement Labeling Syringes 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. 1. Use the data collection process you described in Step 4, modify if necessary 2. 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.

# 8 Re-Measurement Labeling Syringes Random observations of “Labeling Syringes” by the Anesthesia providers was completed by the DON in September; Which included direct observation of labeling of syringes of 3 Center Anesthesiologists and 2 CRNA’s for a total of 96 procedures.

#9 If You Have Not Met Your Goal Labeling Syringes Each of the elements of the Labeling of Syringes audit WAS met 100% of the time during the September audit period 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. What are you doing to reach your goal, that is different than your re-measurement? Counseling Staffing Change

# 10 Communication of Your Findings Labeling Syringes How are you communicating the QA 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)? Results were reviewed with the Medical Director and shared during the quarterly Governing Board Meeting; the Board recommended continued monitoring for an additional 6 months.

For Additional Information Contact Information For Additional Information Marcy Sasso, CASC marcy@sassoASC.com (862) 812-5611