AS I SEE IT
Stop Guessing, Start Measuring Choose meaningful, data-based QAPI study topics BY DAREN SMITH
The purposes of quality assurance and performance improvement (QAPI) for ASCs are quite clear. In fact, they are spelled out
for you: “quality assurance,” mean- ing care is maintained at an acceptable level, and “performance improvement,” meaning changes are implemented to strengthen operations. Achieving the objectives of QAPI,
however, can be a challenge for some ASCs. Failure to properly perform QAPI studies can put an ASC into reg- ulatory hot water with the Centers for Medicare & Medicaid Services (CMS) and jeopardize accreditation status. Just as importantly, a poorly perform- ing QAPI program can cause an ASC to miss opportunities to make changes that can positively affect clinical, oper- ational and/or financial performance. Fortunately, maximizing the ben- efits of QAPI while meeting require- ments and standards is not difficult. Doing so essentially boils down to using data most ASCs already collect.
Understanding Expectations To understand the importance of data for QAPI, it is important to first understand the QAPI requirements. They are fairly vague, with CMS stat- ing ASCs must perform QAPI studies but not providing a specific number. The recommendation one typically hears in the industry is that the num- ber is dependent upon facility size. If you work in a smaller ASC with low case volume, there is an expectation that you should perform at least one or two studies annually. Work in a larger ASC with thousands of cases, this figure should fall in the four-to- six studies range.
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One reason CMS does not spec- ify a number of studies that an ASC must perform might be that the num- ber should change on an annual basis to reflect activity within the facility. Identify a topic worthy of a study, then do it. Going back to our discus- sion on the purpose of QAPI, a good program will help you flag issues that might be affecting your ASC, which should prompt you to investigate those issues further and then, if nec- essary, make improvements. Surveyors—whether from CMS or the accreditation organizations, which follow CMS’ methodology for QAPI, albeit with subtle differences and nuances—will be looking to see whether your ASC is using data to identify and resolve those issues. Why data? It is difficult to con- fidently state whether there is truly a
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problem without evidence, i.e., data, and difficult to claim improvement has been achieved without evidence.
What Goes Awry On the surface, QAPI seems straight- forward, but ASCs can get tripped up in their efforts to perform appropriate, worthwhile studies. One place an ASC could err is to focus on an area not wor- thy of attention. For example, many people working in the ASC industry will recall when recommendations stat- ing that use of a straight-edged razor was not appropriate for surgical site hair removal were issued. At that time, when some providers were still using straight-edged razors in ASCs, a QAPI study could have looked at the fre- quency of physicians using such razors and the effectiveness of changing pro- tocol to move away from the razors.
The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion.
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