“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 Contracts Preventative Maintenance Patient Satisfaction Chart Audits Peer Review Credentialing Minutes * Quarterly Meetings Education In-Services *Document all QA Activity

Drills, Safety & Rounds Malignant Hyperthermia- General Anesthesia Annually Fire, With Scenario, And Transmission Form Quarterly Disaster, With Scenario Every 6 months Code Blue Annually Fire Extinguishers, Eye Wash, Facility Rounds

Why Have a Quality Program Anyway? It’s REQUIRED for CENTER ACCREDIDATION TJC AAAHC AAAASF 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 checklist May 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 room Applies to all ASCs, including GI endoscopy centers Measurement from January 1, 2012 through December 31, 2012 Web Based Reporting via Quality Net

Selected Procedures Procedure Category Corresponding HCPCS Codes: 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 Team What 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 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. 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 Impact During 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 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.

#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 PLAN Booking forms getting lost in fax; new dedicated fax line Continuous repairs; change vendor New 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 Benchmarking ASC Quality Collaboration www. ascquality National Benchmarking ASC 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 Cancellations, you have the most control over Why are cancellations occurring, is it the same physician or group If you are receiving less than 30% patient satisfaction returns, look at your process

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 Are staff doing pre-certification on all patients Are claims going out clean Are some physicians using the top of the line supplies Is the block time to loose Why are OT dollars occurring, do you use per diem

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

Average AR Days Per Insurance Carrier Internal

Hand Hygiene Monitoring Internal

Patient Hospital Transfers Internal

Q2 Patient Survey Return Rates External

Calendar of 2014 ASC Studies Sasso Consulting, LLC

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 Center www.cms.gov/center/asc.asp Quality Net website (CMS Specifications Manual) www.qualitynet.org

For Additional Information 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”