follow the same process for QAPI, Kirchner says. “They have different views from one another for how QA and PI should be done and reported,” she says. “For example, the Accredi- tation Association for Ambulatory Health Care (AAAHC) essentially dictates how the QA and PI have to be done. Basically, ASCs follow a 12-step process and line up their pro- gram to each of the steps AAAHC has identified in its regulations. If you’re going with AAAHC, you need your program to follow their expectations because if it doesn’t, AAAHC won’t pass your organization. They want your program in that format. It’s im- portant to be aware of the format of whoever is accrediting you.”
Begin with a Mission Statement While there may be some differences in how ASCs should approach devel- oping a QAPI program, Kirchner says the plan should begin with a mission statement. “The mission statement is very similar to the mission state- ment you have for the facility, but in this statement, it’s going to discuss how you monitor your processes,” she says. “Are you auditing? Are you observing? Are you proactive or reac- tive? How are you going to track an issue when it is identified?” King agrees. “The program should
be linked to the facility’s mission and vision statement as well as reflect its core values as a means of incorporat- ing certain philosophies and princi- ples,” she says. Development and approval of this mission statement, like all elements of the QAPI program, need to involve the governing body, Kirchner says. “In the Conditions for Coverage, Sec- tion 416.41 talks about what the gov- erning body is responsible for and has accountability for,” she says. “Right at the top of Section 416.41, it says it is responsible for oversight and has total accountability for the QAPI program.”
“The governing board’s under- standing and commitment to such a program both through discussion and documentation remains a top priority since this group is held ultimately ac- countable for all facility operations,” King adds.
Development of a QAPI Committee There are many people who should be included in your QAPI committee, Kirchner says. The number of people involved will vary depending on the size of the facility and the number of employees. “You should always have a chair,” she says. “This is somebody who is ultimately responsible for hold- ing the meetings, preparing the agen- da and making sure the minutes are
You must not forget your business of- fice in this process.” With the QAPI committee formed, Kirchner says she makes sure all com- mittees answer up through the QAPI. “Under the QAPI committee, I put safety, infection control and preven- tion, pharmacy, employee health, ra- diation safety, and then if I have other committees like nursing care commit- tees where we’re working on new poli- cies and procedures, they also answer up to the QAPI committee,” she says. The QAPI committee is responsible to the administrator, Kirchner says. “The administrator needs to oversee the QAPI committee or delegate that to somebody with authority to oversee it. Most administrators oversee it them-
The program should be linked to the facility’s mission and vision statement as well as reflect its core values as a means of incorporating certain philosophies and principles.”
—Cindy King, Health Inventures, Westminster, Colorado
written and follow-up is performed. You really should have at least one an- esthesia provider, one surgeon, and at least one of the major leaders in your organization—such as your center ad- ministrator or your clinical coordina- tor or charge nurse—involved in the organization’s day-to-day operations. “And you need to include your
staff in this,” Kirchner continues. “This committee needs to be made up of staff members who are working day to day and can identify problems and seek answers. I usually recommend having at least one nurse who works in the operating room, one nurse who works in admissions or pre-op and one nurse who works in PACU. I al- ways include the infection preven- tionist nurse, the safety officer and the risk manager, if different from the administrator. Then you need to have one person from your business office.
selves. Moving up the committee orga- nizational chart, the QAPI committee and administrator are responsible and make recommendations to the ASC’s medical executive or medical advisory committee. They have a place in the QAPI, especially when it comes to the services and type of care patients are receiving. Then you have the board at the top of the organizational commit- tees chart as it is ultimately responsible and accountable for all actions taken.”
Core Elements Stinchcomb advises ASCs to break their QAPI program down into dif- ferent areas. “One of those areas is ongoing evaluation of your services,” she says. “For example, the pharmacy consultant comes into your facility every month. Assuming your proce- dures and processes are not changing much, odds are pretty good that your
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