MAKING QAPI PAINLESS It doesn’t have to hurt!! Joan Balducci, RN, BS NTF Management, LLC 201-264-8424 June 2nd, 2011

We all strive to be the best that we can be! In order to be the best, an organization must maintain an active integrated organized ongoing data driven peer-based program of quality management and improvement that links peer review, Infection Control and risk management in an organized systematic way. This can be a daunting task. The solution is to break it down into smaller parts and understand how all aspects are interrelated.

Quality Improvement Program. Ambulatory surgery centers are expected to maintain an active integrated organized and peer-based quality improvement program which should include; 1. A description of the program which addresses the scope of services and how the quality improvement plan is assessed. 2. Identify specific committees or individuals responsible for the development, implementation and oversight of the program 3. Who participates in the program. ______________________________________ ______________________________________ ______________________________________ ______________________________________

Continued 4. State what the goals and objectives are. 5. Develop a process to identify important problems and concerns to address in order to improve the quality and safety of the services provided by the organization. 6. Identify quality activities, which must include internal and external benchmarking. 7. Define the linkages between the Infection Control activities Peer Review and Risk Management programs. 8. The focus is to be on whether the ASC has an on-going, data driven system, not whether an ASC has deficient practices.

The Role of The Governing Body There must be a written process to report the findings of the Quality Improvement activities to the Governing Body and throughout the organization. All reviewing organizations will be looking for documentation in the various meeting minutes to ensure that the QI information is being disseminated throughout the center to staff and physicians. _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _________________________

Quality Indicator Tracking Sources of Data Pt. Complaints Pt. Questionnaires Occurrence Reports Physician Input QI Adverse Incidents Staff Input Facility Logs Audits Quality Indicator Tracking

Where Do We Begin? 1. Make sure you have an active, ongoing peer review program. This includes surgeons, chiropractors, anesthesiologists, CRNA’s, RN first assists, PA’s and nurse practitioners and any other allied health professional. __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________

What Should Be included In My Peer Review Policy? This depends upon what organization you are trying to comply with. Check out the standards of your accrediting organization, the Medicare Conditions for Coverage NJDH&SS state regulations. 1. Determine how many physicians will participate in the chart review process. 2. How often will the charts be reviewed? 3. How many charts will be reviewed?

Continued 4. The items to be monitored should be specific to that specialty. 5. Develop a tool that lists the items being reviewed, by whom, date, and findings. 6. If the organization is a solo physician practice, an outside physician should be engaged to do the chart reviews. 7. In addition, to the periodic chart reviews, charts of all patient related occurrences and adverse incidents should be completed in addition to the routine number. ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________

Continued 7. The findings should be reported to the appropriate committees and Governing Body and noted in the Governing Body minutes. 8.Prior to re-credentialing and privileging all peer review records should be reviewed by the appropriate committee. 9.Recommendation or denial of renewal of privileges to the Governing Body are based on these findings. _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________

Risk Management Every center needs to develop and maintain a risk management program appropriate for that organization. Its goal is designed to protect the life and welfare of the organization’s patients and employees as well as to protect the center’s assets. _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ ___________________

Elements of a Risk Management Plan Be consistent throughout the organization on all levels Patient dismissal from care Reporting, reviewing and analyzing all occurrence reported by employees, patients, healthcare professionals, and others. Do track occurrences of all facility systems as well. Review all deaths, trauma and any other adverse incidents Review and investigate all infection control occurrences and possible breaches. Review all patient complaints and if the complaint was directed at a clinical issue that sure must be reviewed as well. Keep communications open with your malpractice carrier. A policy or how you would manage the situation if a healthcare professional becomes incapacitated or arrives at the center impaired. Communicate and document that each patient has received instructions for care after hours.

Continued Prevent unauthorized prescribing by locking up or prescription pads. Policy and process on-site and side Develop a process for tracking all communicable diseases by visitors, staff, physicians and patients. Report to the appropriate local agency is mandated by the New Jersey Department of Health and Senior Services. Develop a policy and procedure for visitors, observers, surveyors, vendors or other physicians who need to be present patient care areas. Periodic review of clinical records and clinical record policies from a Risk Management perspective Track all maintenance records of essential medical equipment, computer systems, telephone systems, generator, anesthesia machines and HVAC to identify any trends that may indicate a problem with these items.

Infection Control and Patient Safety All ASC’s must maintain ongoing programs designed to prevent and control infections and communicable diseases and provide a safe and sanitary environment care. Infection Control: Approved by the Governing Body An integral part of the Quality Improvement program Under the direction of the designated qualified healthcare professional who has training and current competence and infection control Meets all applicable state and federal requirements Provide a plan for preventing ,identifying and then managing infections and communicable diseases and for immediately implementing corrective and preventive measures that result in improvement

Six Key Functions of an Effective Program 1. Maintenance of a sanitary environment 2. IC practices by clinical and medical business office staff, and on-site contract and vendors. 3. Mitigation of risk associated with HAI 4. Identifying infections and communicable diseases with reporting as mandated by the NJDH & SS. 5. Monitoring compliance with all program requirements 6. Evaluation/revision of the program when indicated. *** It is not enough to have detailed policies without demonstrating adherence in the practice. ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ____________________________________

Annual Review for QAPI Effectiveness The Quality Improvement program must be evaluated for its effectiveness at least annually and documented in the Governing Body meeting minutes. The ongoing program must: Demonstrate measurable improvement in patient outcomes Improve patient safety by using: Quality indicators associated with improved outcomes ID and reduction of medical errors ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

Summary 1. The Governing Body has total responsibility and has to be involved 2. Show linkages between Peer Review, Risk Management and Infection Control. 3. Good documentation in meeting minutes showing the linkages. 4. Read and review the NJDH & SS Regulations, your accrediting body’s standards and the Medicare Conditions for Coverage regularly. 5. All these standards are a day to day way of life if you are going to be successful. 6. Get everyone involved so the behaviors become habit.