Don’t Let QA/PI Give You the Blues: Starting, Maintaining and Presenting Your QA Program Sarah Martin, MBA, RN, CASC Vice President of Operations Meridian Surgical Partners
Creation of a Quality Program 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
CMS QA Program Scope • 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: • • • •
Quality indicators Adverse patient events Infection control Other aspects of patient care and services in the ASC
Quality Encompasses Many Areas • 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
CMS QA Program Activities 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
Determining Indicators High risk, volume and problem‐prone: • • • •
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?
Developing Quality Measures Recommend using the National Quality Forum (NQF) endorsed quality measures: • • • • • •
Patient Falls Patient Burns Hospital Transfer/Admission Wrong Site, Side, Patient, Procedure, Implant Prophylactic IV Antibiotic Timing Appropriate Surgical Site Hair Removal
Additional Quality Measures • Infections • Medication errors • PACU >2 hours • Patient death • Return to surgery • Employee incidents • Case cancellation after patient is admitted • Sharps injuries • Other unexpected complications
Business Quality Measures • Dictation delays >48 hours • Collection goals met • AR days compared to goal • Number of incorrectly scheduled procedures • Number of chart reviews completed
QA Activities: Be Ongoing and Data Driven • 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
Quality Studies • 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
Quality Study Ideas • Ideas can come from many areas: • • • • • • • • •
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
Patient Satisfaction • 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”
Identify Ways to Reduce Medical Errors 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”
Investigation of Adverse Events • Investigate causes: Root Cause • Implement improvements: Could require a QA study, change in policy and procedure • Ensure improvements are sustained: Monitor outcomes ongoing
Infection Control 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
Infection Control Plan • Development and implementation of IC measures • Maintain a sanitary environment • Identify infections • Mitigate risks of associated HAI
Infection Control Plan • Active surveillance • Address communicable diseases • Monitor compliance with policies, procedures, protocols of IC program • Evaluation of IC program
Mitigation of Risks • Antibiotic prophylaxis • Proper sterilization technique • Proper aseptic technique • Hand hygiene • GIVE TOOLS: Hand and Mask Surveillance
Mitigation of Risks • Safe injection practices • Proper use of disinfectants and germicides • Patient, family and staff education
What To Do With The Data? • 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?
What To Do With The Data?
Governing Body 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
Documentation of QAPI Program • • • • •
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
Documentation of QAPI Program • • • • •
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
Safety as Part of QAPI • • • • • •
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
Risk Management as Part of QAPI • 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
Presentation to 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