“ Quality Program for Surgery Centers

1. “Quality Program for Surgery Centers MarcySasso, CASC

2. 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

3. Quality Program- It’s a Name • Quality Assurance QA • Quality Improvement QI • Performance Improvement PI • Quality Assurance Performance Improvement QAPI • Total Quality Management TQM

4. 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

5. Quality Indicators… Just a FEW Infection Control BBP Exposures Volume and Procedure Statistics Specimen Errors Occurrence ReportsLogs Procedure Complications Patient Wait Times Sedation/Anesthesia Complications Staffing Levels Turnover Rate Start Times Cancellation Rates Safe Injection Practices Scope Reprocessing Poor Preps

6. Continual Quality Examples Contracts Preventative Maintenance Patient Satisfaction Chart Audits Peer Review Credentialing Minutes * Quarterly Meetings EducationIn-Services *Document all QA Activity

7. 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

8. Why Have a Quality Program Anyway? It’s REQUIRED for CENTER ACCREDIDATION TJC AAAHC AAAASF Medicare- CMS To PROVIDE QUALITY PATIENT CARE

9. 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.

10. 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

11. 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

12. 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)

13. Influenza Vaccination ASC- 8Influenza 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

14. 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

15. 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

16. 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. • 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 ______________

17. # 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.

18. # 2 Identification of the Performance GoalMedical Records Where Do We Want To Be? Expected Outcome/Goal: 100% Compliance of the Required Medical Record Elements Actual Outcome: Initial study, TBD

19. # 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

20. # 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

21. # 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.

22. # 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?

23. # 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.

24. # 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.

25. #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

26. # 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.

27. 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

28. 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”.

29. 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.

30. 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.

31. What Can You Benchmark? Everything and Anything that Occurs Within Your Center

32. Types of Benchmarking INTERNALLooking within your Own Center EXTERNALComparing with Like Center NATIONALComparing with National Center

33. Internal Benchmarking • Physician to Physician • Supply Costs Per Vendor • Benefits- Salaries • Hand Hygiene • Chart Audit • Compare Last Years Numbers to Current Numbers

34. External Benchmarking • Benchmark with other Center’s that are the same Specialtyor Sizeas 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

35. National BenchmarkingASC Quality Collaboration www.ascquality.org ASCA asc@ascassociation.org

36. 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

37. 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

38. 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

39. 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

40. Patients Seen Per Quarter 2013 Internal

41. Average AR Days Per Insurance Carrier Internal

42. Hand Hygiene Monitoring Internal

43. Patient Hospital Transfers Internal

44. Q2 Patient Survey Return Rates External

45. Calendar of 2014 ASC StudiesSasso Consulting, LLC

46. 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

47. Contact Information For Additional Information Marcy Sasso, CASC marcy@sassoASC.com (862) 812-5611 Madison, NJ 07940

48. Thank You for Participating in “Quality For your Surgical Center”