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ADVOCACY SPOTLIGHT


MEMBER PROFILE


MICHELLE GEORGE, RN, CASC


Title: Senior Director of Clinical Services Facility Name: Surgical Care Associates City: Pasadena State: California


Q What are the essential steps to designing and


implementing a successful clinical benchmarking program?


A Clinical benchmarking programs are a critical element in the ASC’s


quality assessment and improvement program. The first step to designing and implementing a successful clinical benchmarking program is to gain clarity around why the program is being established. Once the team has clarity around the purpose of its program, there are a few essential steps required to set up the benchmarking program.


Setting up the Program: Your program needs to incorporate a


ing guidance and the evolution of where this pandemic is going.” COVID-19 testing has evolved


over time and has become more widely available, Blackwell says. “Several of our ASCs are able to administer the tests and send these to a lab for analysis,” she says. “We have been able to administer the gold-standard test in several of our centers to detect the SARS-CoV-2 virus, the Real-Time Reverse Tran- scriptase (RT)-PCR diagnostic test. CDC does not recommend antibody testing to detect an active infection.”


regular and systematic cadence of measuring services and programs. Start by determining what you want to measure or improve. In an environment where resources are limited and often one individual fills multiple roles, it is important that benchmarking efforts target areas most important to your center’s overall growth and quality outcomes.


Metrics and Data Collection: In designing your program, identify metrics that are congruent with what you want to measure. They need to be consistently accurate and retrievable within your systems. Metric definitions need to be consistent within your industry and a match to any external benchmarking sources that you plan to use.


Performance Comparison: Internal benchmarking, or comparing your current performance with prior periods, is important to understanding whether you are making progress toward established goals and targets. External benchmarking provides insight into how your performance compares to industry performance and identifies those areas that you can focus on as improvement opportunities.


Analysis and Planning: In this step, the quality committee members review their


Testing has come a long way since


the ASC QC did its survey back in spring 2020. “The low infection rate that was found in the survey predates the imposition of a lot of these new screening and testing measures that ASCs are now making a common- place part of their healthcare pro- cess,” says Bill Prentice, chief execu- tive officer of ASCA. “That makes me think that extraordinarily low infec- tion rate from the survey is proba- bly going to be even lower if we did another survey today, now that we are using enhanced screening and testing


outcomes, compare their processes to evidence-based or best industry practices, and develop strategies to close the gap between current performance and industry performance.


Reporting: Evaluate your performance through comparison to prior performance periods, usually monthly or quarterly. This cadence is a good marker for your reporting schedule as well. The team or quality committee responsible for understanding the ASC’s performance and developing the strategies for improvement needs detailed insight into how its processes and outcomes compare to the best in class. A high-level summary of findings and overview of future strategy is generally adequate when reporting to executive teams such as your medical executive committee and governing board.


Your performance improvement plan and clinical benchmarking program provide the structure to understanding performance, but it is communication and engagement of your team and medical staff that is truly the key to moving the needle on your benchmarks. To be effective, your program metrics and targets need to evolve as your programs expand and your performance improves over time.


mechanisms that probably were not fully in place when that first survey was conducted.” The ASC QC was formed in 2006, bringing together leaders from both the ASC industry and organizations with a focus on healthcare quality and safety. Today, its efforts are focused on quality measure development, the pub- lic reporting of quality data, advancing ASC quality and advocacy.


Sahely Mukerji is the editor of ASC Focus magazine. Write her at smukerji@ ascassociation.org.


ASC FOCUS FEBRUARY 2021 | ascfocus.org 23


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