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ASC quality benchmarks Archives - Pinnacle III

Nov 14
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Understanding the Administrator's Role in ASC Quality Improvement

Understanding the Administrator’s Role in ASC Quality Improvement

By ASC Management, Leadership No Comments

A quality assurance performance improvement (QAPI) program has long been the foundation for the delivery of quality care in an ASC. That’s because an effective QAPI program helps improve all aspects of an ASC’s operations. Despite its longstanding importance, ASC quality improvement has taken on greater significance in recent years.

There are a few reasons why. Physicians, staff, regulatory bodies, payors and even patients are demanding increased transparency concerning quality and quality improvement data. Accreditation organizations are requiring a high-level QAPI process to meet standards. Reimbursement is increasingly tied to quality measures and outcomes. Reports of poor quality tend to make the news and spread like wildfire.

This makes it vital that a QAPI program be an organizational commitment for ASCs. It is the administrator’s responsibility to secure such a commitment from employees, management, physicians and the governing board. To do so, an administrator must be an active participant in ASC quality improvement and embrace the steps necessary for success.

10 Steps for Administrator Involvement in ASC Quality Improvement

Here are 10 steps administrators can follow to help ensure effective involvement in their ASC’s QAPI program.

  1. Understand your program. Allocate the time necessary to learn about your QAPI program, plan, and processes. Without a strong understanding, administrators cannot provide effective oversight and participation.
  2. Learn requirements. If your ASC delivers care to Medicare and/or Medicaid patients, you are required to meet the Centers for Medicare & Medicaid Services’ (CMS) QAPI requirements. As noted earlier, if your ASC is accredited, your QAPI program must comply with accreditation standards. While there is likely overlap between the requirements, there may be some differences. Understand what surveyors expect to see when they visit your ASC.
  3. Focus on what matters. ASC quality improvement can feel overwhelming when you’re unsure what areas of operation to focus on for improvement. Study performance data and identify those measures and benchmarks critical to your success. This will help ensure you measure, track, trend, report on, and improve what is most important to your ASC.
  4. Carefully select a program manager. While administrators should be active participants in ASC quality improvement, they do not normally serve as the QAPI program manager. Rather, they select and appoint a responsible individual. This person, who is often a nurse, must have interest, knowledge, and experience in quality improvement. Passion for improving care is vital to your QAPI program manager’s success. Also critical: administrative and organizational skills, including using spreadsheets and databases, and developing meaningful presentations for QAPI committee meetings. Note: Maintain a current, clear QAPI program manager job description for guidance and accountability.
  5. Establish oversight. Develop a process to ensure effective oversight of the QAPI program. Follow your organizational chart to maintain accountability of the employee responsible for the QAPI program. Include yourself on that chart as you will likely work directly with the QAPI program manager on specific projects.
  6. Support the program. A surefire way for a QAPI program to fall short of its potential is lack of support. Provide resources critical to a successful program. These can include time for the manager to work on ASC quality improvement, training, education (e.g., industry conferences, webinars, publications) and software. It also includes authority for the QAPI program manager to hold stakeholders accountable.
  7. Be active on committees. Take an active role on your QAPI committee. This will help you provide a comprehensive summary about QAPI activities to your medical advisory committee (MAC) and governing board.
  8. Serve as interface. As administrator, you are the interface between staff, physicians, MAC, and the governing board. You are responsible for maintaining an efficient flow of information regarding QAPI activities that help achieve objectives. Work closely with the MAC and governing board to ensure implementation of their directives.
  9. Stay involved. QAPI programs are most successful when administrators are continually involved, even when the program is delivering strong results. Such involvement demonstrates commitment and support. It also provides the opportunity to share input on benchmarking and studies appropriate and important to QAPI priorities.
  10. Keep current. Healthcare is a dynamic sector, undergoing frequent changes. This extends to ASCs. Administrators must keep abreast of industry changes that impact ASC quality improvement efforts. When changes arise, incorporate revisions to your QAPI process to meet new needs and requirements.

ASC Quality Improvement Quick Tips

The steps outlined above should help define your role in your QAPI program. Here are a few tips that can further boost your ASC quality improvement efforts:

  • Rely on your data. Using data helps administration make evidence-based decisions, allocate resources more effectively, and engage in targeted corrective actions.
  • Involve many staff in your QAPI program. This will help create a learning organization where ASC quality improvement processes are understood and improvements are sustained and built on.
  • Promote your program. Keep QAPI as a top-line item for MAC and governing board meetings. Share program results and explain how they improve your ASC. Provide this information to payors to further demonstrate your ASC’s commitment to quality.
  • Leverage partner support. If your ASC has a management company and/or hospital partner, its QAPI expertise can be an asset to the manager and program.

The importance of QAPI and ASC quality improvement efforts are likely to magnify as the demand for quality information and data grows. Quality improvement must be an ongoing effort if ASCs want to achieve meaningful results and maintain compliance. By carefully balancing their participation with QAPI program oversight, administrators can play a crucial role in achieving these objectives.

Ross Alexander, Director of Operations

Oct 26
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ASC Vendor Contracts – How to Track Service and Save Time!

ASC Vendor Contracts – How to Track Service and Save Time!

By ASC Management No Comments

Surgery center stakeholders expect administrators to proactively evaluate ASC vendor contracts and continually assess vendor performance to ensure their ASC is receiving high-quality services. These tasks not only ensure ASC operations run smoothly and cost effectively but maintain compliance with expected quality metrics.

ASC vendor contracts are defined as services obtained from an agency or vendor external to the facility. Examples of vendor contracts your surgery center may hold include laundry, environmental services, transcription, medical waste disposal, lab/pathology, etc. Your medical supply distributors also fall under the vendor classification.

While this task may seem time-consuming and onerous, here are some ideas on how to streamline the process of regularly assessing if your vendors are meeting your needs.

First, get organized. A best practice is keeping all your ASC vendor contracts in one location where they can easily be accessed. A hard copy contract binder or an electronic folder with multi-user access may meet this need. Establish a master list or spreadsheet of all the service contracts held by your facility. Include information for each vendor – contact information, expiration dates, billing cycles, and service(s) provided. File the master list at the front of your contract binder or on your computer desktop for frequent reference. This list will come in handy for monthly OIG verifications and periodic quality reviews.

Your facility’s quality plan should include an annual review of your ASC vendor contracts. Tracking the quality of the services provided by external vendors is essential. This is because the facility holds ultimate responsibility for the provision of quality services regardless of who is supplying them.

To assess ASC vendor quality, set up one or two measurable, mutually-agreed upon benchmarks or goals. For example, you might establish a benchmark with your laundry service to send no more than ten pieces of torn or unusable linen items to your facility per quarter. Or, you may want to track the return rate of your pathology reports to determine if they are received within the contracted terms. You could track your medical supply distributor’s fill rates to determine if they are meeting your expectations. Tracking controlled variables may prompt you to establish other benchmarks and formalize them in your service contracts. Schedule periodic meetings with your vendors to share measurable results and any new expectations.

Once quality measures are established, add them to your master list. Leave extra space to record the status of each quality measure and a section for comments regarding quality or service. Make sure any poor or unsatisfactory ratings are backed up with specific comments. Explain any non-compliance issues by comparing them to your set standards. Remember to document positive comments for excellent service.

Review poor ratings to determine if there are any trends in declining service. The service review process and subsequent actions taken may lend itself to a quality improvement study. You can use these trends to decide if you need to meet with vendors for corrective action or if it’s time to vet out other vendors for a possible change in service. Be careful not to jump to conclusions. Give vendors a reasonable amount of time to address identified issues.

Combining quality indicators and service assessment into an ASC vendor spreadsheet makes annual presentations to your governing body organized, concise, and relative. This tool also serves as a tremendous time saver because you can proactively address ASC vendor contract expirations, quality assessments, and service expectations. Last, but certainly not least, this system allows you to identify problems early and establish improvement plans with your vendors. If efforts to improve fall short, recommendations to the governing board to change vendors are more likely to be met with support and buy-in due to your continuous documentation, due diligence, and assessment.

Implementing this process will earn you a pat on the back for saving time, while simultaneously addressing quality, due to your strong planning and organizational skills. That’s a win-win for everybody!

Kelli McMahan, VP of Operations