Don’tLetQA/PIGive
YoutheBlues:
Starting,Maintaining
andPresentingYour
QAProgram
Sarah Martin, MBA, RN, CASC
Vice President of Operations
Meridian Surgical Partners
CreationofaQualityProgram
Must meet the requirements of CMS 2009 Conditions of Coverage § 416.43
• Program must be ongoing and data‐driven
• Follow the standards for your accrediting body
• Meet any state requirements CMSQAProgramScope
• Program must demonstrate measurable improvement in patient health outcomes
• Improve patient safety using quality indicators or performance measures
• Identify ways to reduce medical errors
• Measure, analyze and track:
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Quality indicators
Adverse patient events
Infection control
Other aspects of patient care and services in the ASC
QualityEncompasses
ManyAreas
• Peer review: Quality of providers
• Chart review: Quality of documentation of care
• Benchmarking: Quality of how you compare to others
• Risk Management: Quality of identification and prevention of occurrences
CMSQAProgramActivities
Quality indicators can be focused on:
• Outcomes • Process of care issues
• Patient Perception
Quality Indicators should:
• Focus on high risk, high volume, problem‐prone areas
• Consider incidence, prevalence and severity of these problems
• Affect health outcomes, patient safety and quality of care
DeterminingIndicators
High risk, volume and problem‐prone:
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What are your high risk procedures?
Who are your high risk patients?
What are your high volume procedures?
What are your problem‐prone procedures?
Incidence= rate of frequency at which problems occur
Prevalence= how widespread is the issue?
Severity= how serious is the event, even if it occurs only once
Will tracking this improve patient outcomes and increase safety?
DevelopingQualityMeasures
Recommend using the National Quality Forum (NQF) endorsed quality measures:
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Patient Falls
Patient Burns
Hospital Transfer/Admission
Wrong Site, Side, Patient, Procedure, Implant
Prophylactic IV Antibiotic Timing
Appropriate Surgical Site Hair Removal
AdditionalQualityMeasures
• Infections
• Medication errors
• PACU >2 hours
• Patient death
• Return to surgery
• Employee incidents
• Case cancellation after patient is admitted
• Sharps injuries
• Other unexpected complications
BusinessQualityMeasures
• Dictation delays >48 hours
• Collection goals met
• AR days compared to goal
• Number of incorrectly scheduled procedures
• Number of chart reviews completed
QAActivities:
BeOngoingandDataDriven
• Data is collected regularly: recommend monthly
• Data is analyzed regularly: recommend monthly
• Benchmark results nationally and internally
• Actions are taken as appropriate in response to data: ASAP
• Data is reported: recommend at least quarterly
• Quality Committee
• Governing Body
QualityStudies
• Use the 10‐step process
• Give yourself credit for the things you are doing
• Evaluation of a new procedure or product can be written as QA:
• Lap banding
• Total joints
• Trialing a less expensive anchor
QualityStudyIdeas
• Ideas can come from many areas:
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Satisfaction surveys
Staff Articles in healthcare magazines
Your peers
Unexpected outcomes
Variances from expected performance
Outdated/non‐working practices or policies
Legal issues
Wasteful practices
PatientSatisfaction
• Gather data monthly: % of returned surveys
• Give to patients of all specialties and procedures
• Determine how many to distribute
• Determine goal: • Track % compared to goal
• Follow up on areas rate less than “good”
IdentifyWaystoReduce
MedicalErrors
Required to track these occurrences
• Determine if errors caused the event and could have been preventable: get to the root cause
• Reduce the likelihood of future events
Staff must be trained on Adverse Events
• Definitions of an adverse event and errors
• How the facility seeks to avert and limit adverse events
• Know how to report these occurrences
Definitions
• Error is defined as “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”
• Adverse Event is defined as “an injury caused by medical management rather than the underlying condition of the patient”
• An adverse event attributable to error is a “preventable adverse event”
InvestigationofAdverseEvents
• Investigate causes: Root Cause
• Implement improvements: Could require a QA study, change in policy and procedure
• Ensure improvements are sustained: Monitor outcomes ongoing
InfectionControl
Infection control program has its own standards at §416.51(b) but is an integral part of your QAPI program as well
• Ongoing program to prevent, control and investigate infections and communicable diseases
• Document use of nationally recognized IC guidelines
• Under direction of IC professional
InfectionControlPlan
• Development and implementation of IC measures
• Maintain a sanitary environment
• Identify infections
• Mitigate risks of associated HAI
InfectionControlPlan
• Active surveillance
• Address communicable diseases
• Monitor compliance with policies, procedures, protocols of IC program
• Evaluation of IC program
MitigationofRisks
• Antibiotic prophylaxis
• Proper sterilization technique
• Proper aseptic technique
• Hand hygiene
• GIVE TOOLS: Hand and Mask Surveillance
MitigationofRisks
• Safe injection practices
• Proper use of disinfectants and germicides
• Patient, family and staff education
WhatToDoWithTheData?
• Data monitors effectiveness, safety and quality of services
• Identifies opportunities for improvements in patient care
• Use data to develop performance improvement projects
• Number and scope must reflect scope and complexity of the services and operations
 Must have one or more per year
 Not prescriptive on types of projects
• Must document performance improvement projects
 At a minimum, document reason for project
 Describe results
 If successful, are results sustained?
WhatToDoWithTheData?
GoverningBody
Responsibilities
Governing Body must ensure that the QAPI program:
• Is defined, implemented and maintained by the ASC
• Addresses the priorities
• Improvements are evaluated for effectiveness
• Data collection methods, frequency and details are specified
• Expectations for safety are clearly established
• Allocates sufficient staff, time, information systems and training to implement the program
Documentationof
QAPIProgram
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Defined in writing and reflected in Board minutes
Written evidence of implementation of program
Implemented on an ongoing basis
Quality and patient safety indicators are used
Data collection methodology is defined
Documentationof
QAPIProgram
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Data collected is analyzed
Changes are evaluated for level of effectiveness
Additional changes are made as needed
Identifies patient safety as a priority
Sufficient resources are allocated to the program
SafetyasPartofQAPI
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Maintain a sanitary environment
Safety from Fire
Emergency Equipment (Changed as of 7/15/12)
Persons trained to handle emergencies
Safe administration of drugs
Radiation safety
• SHARE QA MEETING FORM
RiskManagement
asPartofQAPI
• Perform Risk Assessments and Physical Safety Walks: • Analyze data for risk of litigation
• Use identified risks as ways to improve care and safety
• Use of Safe Surgery Checklist is an example of minimizing risks
• Biomedical Equipment checks
• Variance in service from contracted vendors
Presentationto
Board/Surveyors
YOUR SURGICAL CENTER 2012 QA BENCHMARKS
Benchmark
Quarter 1 2012
Patient Burn
Patient Fall
Wrong Site/Side, Patient, Procedure, Implant
Hospital Transfer/Admission
Prophylactic IV Antibiotic Timing
Quarter 2 2012
Patient Burn
Patient Fall
Wrong Site/Side, Patient, Procedure, Implant
Hospital Transfer/Admission
Prophylactic IV Antibiotic Timing
Center results
National results
Variance
Questions?
Sarah Martin, Vice President of Operations
Meridian Surgical Partners
[email protected]
615‐346‐4136