What Should Your QAPI Topic Be? Come to ASCA 2020 and find out BY CRISSY BENZE, RN


Every ASC must have an ongoing Quality Assess- ment and Performance Improvement (QAPI) pro- gram. The primary goals of


this program are to continually and sys- tematically plan, design, measure, assess and improve critical performance indica- tors and patient outcomes, and to prevent errors and injuries.


The scope of a QAPI program includes a comprehensive assessment of the efficacy of performance improve- ment (PI) activities. When it comes to doing a performance improvement activ- ity or study, the question administrators and clinical directors often face is “What topic should I choose?” During our roundtable discussion “How to Conduct a QAPI Study” at the ASCA 2020 Con- ference & Expo in Orlando, May 13–16, I will discuss quality indicators and per- formance measures and how to deter- mine a topic within your ASC. I will begin the discussion with a short pre- sentation and, at the end, attendees will develop QAPI studies in small groups. Whether you call it a quality improve- ment (QI) study or a PI study, you can look to multiple sources for topic ideas: established performance measures, iden- tified problems, incident reports, inter- nal and external benchmarking data, and ideas from the outside, like ASCA Connect and your state association. For example, hand-hygiene compliance is a performance measure monitored by all ASCs. Complete and accurate medi- cal record documentation is another key indicator. You do one random medical record audit every quarter. If the audit uncovers issues, you need to do a deeper dive to identify the specific problems and solutions. Do you need to re-edu- cate staff? Do your medical record forms need to be revised?


Other considerations for a QI topic are patient complaints, staff com- plaints, equipment purchases, patient


8 ASC FOCUS FEBRUARY 2020 | ascfocus.org


ASCs engage in QI activities daily, however, too often we fail to think of our activities in those terms. It may just be a matter of taking credit for the work that is being done.”


—Crissy Benze, RN


processes, contract pricing and the Universal Protocol. Adherence to pro- cesses critical to patient safety, such as hand hygiene and the time out, can always benefit from reinforcement. Once you decide on a topic, plan


exactly what you will measure and your performance goal. Both the efficacy and frequency of hand hygiene can be mea- sured. You may want to focus on one or


ADD THIS SESSION TO YOUR SCHEDULE


“How to Conduct a QAPI Study” is scheduled for Friday, May 15, from 8:00–9:30 am. Attendance for this roundtable session is limited to 100 people, so arrive early to make sure you get a seat. Learn more and review the complete schedule on the ASCA 2020 Conference & Expo website.


ascassociation.org/ annualconference/schedule


the other, or both. Data abounds on the importance of hand hygiene in infection control, proper hand hygiene technique and the frequency of hand hygiene. Determine your focus and set a realistic goal for compliance. Then, gather your data by monitoring compliance through observation. Just because your staff is washing hands, does not mean they are doing it properly. You can use a UV light product to check how effective their hand hygiene really is.


Depending on the results of the data


gathering, education might be neces- sary. Ensure all staff, including the medi- cal staff, are aware of the manufacturer instructions for use (IFU) for the hand antisepsis and surgical hand antisep- sis products stocked in the facility. Post signs strategically throughout the facil- ity with the IFUs and verify that hand hygiene products are readily available to staff in patient care areas. Make it con- venient for your staff to perform hand hygiene. Then, plan a follow-up study to validate the improvement. ASCs engage in QI activities daily,


however, too often we fail to think of our activities in those terms. It may just be a matter of taking credit for the work that is being done.


Depending on your accrediting


organization, a specific QI study format might be required. During the round- table exercise at ASCA 2020, we will use the Accreditation Association for Ambulatory Health Care (AAAHC) QI study format. You should do at least one QI study


each year, but most ASCs always have one in progress.


I hope to see you at our roundtable discussion at ASCA 2020.


Crissy Benze, RN, is a senior consultant at Progressive Surgical Solutions, a division of BSM Consulting, in Incline Village, Nevada. Write her at crissy@pss4asc.com.


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