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Adding Accountability

How to develop a compliant and valuable QAPI program. BY ROB KURTZ


well-designed quality assessment and performance improvement

(QAPI) program can help identify and reduce medical errors. ASCs put QAPI programs in place for many reasons. “They need to do it to meet the requirements—from the Centers for Medicare & Medicaid Services (CMS) Conditions for Coverage (CfCs), any accrediting body that they might be working with and any from their state,” says Debra Stinchcomb, RN, consultant for ASC development and operations consulting firm Progres- sive Surgical Solutions in San Diego, California. “Aside from the regulatory com- pliance rationale of having a QAPI program in an ASC, the expectations of patients, credentialed practitioners, visitors and all other customers who are involved in the engagement of ser- vices from these health care settings remain extremely high, and rightly so,”


says Cindy King, RN, associate vice president, clinical, quality and compli- ance, for ASC management and devel- opment company Health Inventures in Westminster, Colorado. “The focus of this type of program should be on the ability to evaluate the facility’s sys- tems and processes, readily identify problems that have occurred or ones that could potentially occur from exist- ing practices and, then, incorporating follow-up actions as a means toward sustaining performance improvement.” Stinchcomb agrees. “We do mock

surveys at facilities and you can tell the difference, right off the bat, if someone has just written a program that goes up on the shelf and is never dealt with af- ter that versus one that is very robust and one that has the participation of the staff and, most importantly, the governing body,” she says. Beverly Kirchner, RN, president and chief executive officer of ASC developer

and consulting firm Genesee Associates in Southlake, Texas, says QAPI is also important because of what it measures. “First, quality assurance (QA) measures outcomes, and those outcomes should have benchmarks of where you want to be,” she says. “Performance improve- ment (PI) is an entirely different part of it; PI is where you work inside the facil- ity and you identify areas that could have their processes improved.”

Identify Requirements To develop a QAPI program for an ASC, King recommends the facility start by performing some due dili- gence. “Review the involved regula- tory compliance rules, such as state- specific facility licensure laws, CMS’ regulations for ASCs and the ASC’s corresponding accreditation organi- zation’s standards,” she says. “That should provide the facility with an adequate baseline for the develop- ment of its program.” It is important to note that the ac- creditation organizations do not all

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