REGULATORY REVIEW
reporting methods have been straightfor- ward and simple, creating stability and predictability for ASCs. SRE reporting required by the ASC CfCs is more intricate when compared to the ASCQR Program. Under the CfC for Quality Assessment and Per- formance Improvement (QAPI), ASCs are required to develop an ongoing and data-driven program that, among many things, identifies and reduces the occur- rence of SREs. The State Operations Manual: Appendix L provides useful guidance on how to interpret and sat- isfy the ASC CfCs, and while the sec- tion on QAPI leaves much to an indi- vidual ASC’s discretion, it does provide clear definitions and requirements: ■
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Federal regulations require ASCs to document, report and develop strategies to reduce SREs in order to participate in Medicare and receive full reimbursement.
—Steven Selde, ASCA
rather than the underlying condition of the patient.”
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“An adverse event attributable to error is a preventable adverse event.”
“An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).”
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“An adverse event is an injury caused
by medical management
ASCs must track all patient adverse events, in order to determine through subsequent analysis whether they were the result of errors that should have been preventable and to reduce the likelihood of such events in the future. ASCs also are expected to identify errors that result in near misses, since such errors have the potential to cause future adverse events.
ASCs must identify a number of indicators or measures of quality and patient safety, actively collect and analyze data to identify opportuni- ties that could lead to improvements in patient care and develop changes to accomplish those improvements. ASCs must make all staff aware of
the strategies it has adopted for the pre- vention of adverse events. This CfC is similar to many state
SRE reporting requirements. In this CfC and in many states, ASCs are required to develop a thorough program for doc- umenting, preventing and finding the root cause of SREs. This CfC does not require ASCs to use specific SRE mea- sures, and ASCs located in states with SRE reporting requirements may be best served using their state’s SRE measures. Overall, federal SRE programs
requiring ASCs to record and submit SREs have been stable and predictable. SRE-related components of the ASCQR Program and ASC CfCs have not been significantly revised since they were introduced. This is somewhat remarkable considering the policy context SREs are situated in and the hectic pace at which Meaningful Use and other modern fed- eral programs have been modified.
Steven Selde is ASCA’s assistant regulatory counsel. Write him at
sselde@ascassociation.org.
Track the Latest Regulatory and Legislative News for ASCs
Visit ASCA’s web site every week to stay up to date on the latest government affairs news affecting the ASC industry. Every week, ASCA’s Government Affairs Update newsletter is posted online for ASCA members to read. The weekly newsletter tracks and analyzes the latest legislative and regulatory developments concerning ASCs.
www.ascassociation.org/ GovtAffairsUpdate
38 ASC FOCUS JUNE/JULY 2016
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