COVER STORY Patient involvement in QAPI should
not be overlooked, either, King says. “The patients themselves must have the ability to provide input as appli- cable through suggestions, complaints and satisfaction surveys, as well as to receive education and other types of corresponding information when necessary, such as post-op discharge instructions, important notices and/ or alerts such as radiation precautions for those who might be pregnant, the importance of flu immunizations, and coughing and hand-hygiene etiquette,” she says.
Maximizing the Benefits There are a number of steps ASCs can take to make sure that they keep their QAPI program compliant and maxi- mize the benefits it can bring to the facility, staff and patients.
“The best thing to do is use QA and
PI the way it is meant to be used,” Kirch- ner says. “Show that you have audited, show that you have found a problem, show that you have fixed that problem and demonstrate from that day forward that the problem is not occurring again. And never go back and fix a problem— identify it and move forward, because based on the way the Conditions for Coverage read, CMS wants us to audit, wants us to identify problems and wants us to correct our problems. “Lots of people are very good at identifying issues and they’re very good at writing up and collecting data,” Kirchner continues. “Where we sometimes fall apart is we don’t close that loop and show how that data has improved practice or improved pro- cesses or improved safety. What CMS is really looking for is to see us use that data to improve.” For a QAPI program to flourish, it needs resources, and those resources need to come from the governing board. “The governing board is accountable for oversight,” Kirchner says. “You are talking about time, if you need to
“Watch for meeting schedule conflicts; the absence of key individuals and/ or not enough to have a forum; meet- ings that become too long, too short or poorly attended; personalities that are enabled to dominate conversation; lack of member interest; individuals not be- ing fully prepared to report detailed in- formation and meeting packets that are sent out too late for adequate review,” she says (see box on page 14). Kirchner says it will often be dif-
research something, and to cover any costs to buy articles, for example,” she says. “The board is responsible for providing the education that is needed. They need to be prepared to oversee and guide the QAPI committee.”
Kirchner continues, “That being
said, the chair of the QAPI commit- tee needs to make sure that the board of directors gets consolidated reports and has the board approve all PI proj- ects to begin with. Once the PI project is completed, data are collected, the process is changed, the change has taken effect and everybody feels the goals are met, then it’s the board again who has to approve the PI project as complete and also state if it’s to be re- visited. And all of that needs to be in the board minutes.”
There are a number of resources that a QAPI committee might find use- ful, King says. “These include forms for auditing, PI project guidelines, peer review worksheets, information systems—all [these] can potentially enhance the QAPI process as the pro- gram continues to evolve.”
Possible Challenges As facilities mature, a well-established program might face challenges that ASCs should prepare for, King says.
ficult for ASCs to accomplish their QAPI objectives with just quarterly meetings. “I have found that with all of the new requirements, once a quar- ter is not enough, and if you just meet once a quarter, your meeting becomes several hours long and you want to avoid that if possible,” she says. “I recommend you set up a calendar for a monthly meeting that will last no longer than an hour.” If ASCs have questions about es-
tablishing a compliant and beneficial QAPI program, Stinchcomb says, they should not hesitate to contact their accrediting body and ask for as- sistance. “Ask them to help you un- derstand what the standards really are and how you can make a good qual- ity program for your ASC,” she says. “They want to help facilities that they work with succeed.” With the right amount of time, re-
sources and full team buy-in, an ASC can develop a model QAPI program, Stinchcomb says. “From a consultant’s perspective, it’s obvious when an ASC has a robust QAPI program versus one that doesn’t,” she says. “If I walk into an ASC that runs like a well-oiled ma- chine, I can almost read a story in their QAPI meeting minutes. When I talk to the staff, they’re engaged, they under- stand what they’re measuring and they understand how it
all goes together.
Same thing if I’m talking to the board. They have an idea of what their goal is, which is to improve the outcomes and make their facility safer.”
ASC FOCUS MARCH 2013 15
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