“The information required for this report takes some time to gather,” she says. “We are not always notified by patients or the physician’s office that there was an infection. To assemble the report, my infection control nurse reviews patient charts from the office's electronic health records system and then performs all necessary follow-up concerning infec- tions and how they were resolved.” ROSC also typically includes infec-

tions on its QAPI agenda, Barnes says. “We track preoperative antibiotic com- pliance and infection trends and deter- mine where we need to adjust practices.” Recognizing the importance of hand hygiene in preventing infection, Vidant SurgiCenter team members are tasked with completing monthly monitoring and evaluation of hand hygiene compli- ance, Ange says. The results are shared during the MEC meeting. “Good hand hygiene behaviors are reinforced when needed,” she says.

Patient complications—Patient com- plications are always part of ROSC’s QAPI agenda. “Anything we find that could have been prevented needs to be addressed,” Barnes says. “For example, a medication error that could have caused a severe adverse event would need a root cause analysis to determine why it occurred so we could make necessary changes or provide staff education.”

Antibiotic dosing/redosing—Monitor- ing antibiotic dosing and redosing helps Vidant SurgiCenter decrease the risk of postoperative infections, says Nimmo, who also is the ASC's assistant nurse manager. “Monitoring is completed to determine the successful implementa- tion of antibiotic prophylaxis. We look to see if the appropriate antibiotic was ordered, if infusion was initiated within the appropriate timeframe and, if needed, if the antibiotic was redosed appropri- ately within recommended guidelines.”

Risk management—This agenda item covers any “incidences”—a term that covers a wide range of events—that


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occurred at POA Surgery, Bayline says. “If we had a back table cover with a hole in it and did not realize this until the end of the case, that is reported. If we had hospital transfers, employee injuries and cancellations, they are reported. We go so far as to include any patient complaints here. We examine any devi- ations from the level of care we strive to deliver and then work to reduce the chance they will occur again.” ROSC also includes occurrence and variance reports on its QAPI agenda. “We encourage our staff to report any- thing they think is out of the normal,” Barnes says. “This is a way of track- ing trends and finding areas in need of change that will improve patient care.”

Patient satisfaction—Barnes shares her ASC’s patient satisfaction survey results, including all good and bad comments. “The committee members must be aware of our complaints and our praises. This provides information for improvement or recognition of a job well done.”

The patient experience is typi- cally included on Vidant SurgiCenter's QAPI agenda, Ange says. Every patient receives a phone call from one of the ASC’s team members following sur- gery. “We ask for information regard- ing their experience, facility cleanliness and if they had any concerns regarding the care they received, including how they are recovering.”

The employee experience also is a topic of discussion, Nimmo adds. “Engaged employees increase produc-

tivity, help build a strong safety culture and enhance the patient experience.”

Environmental rounds—The POA Surgery Center

report summarizes

the results of a document filled out monthly by rotating clinical staff mem- bers. “They go through the facility and assess everything from refrigerator settings to staff knowledge about fire response to ceiling tiles that need to be replaced,” Bayline says.

QI studies—Barnes provides her MEC with a summary of the ASC's current quality improvement studies and plans for improvements. “This gives commit- tee members an opportunity to share feedback and suggestions. When I pres- ent on the completion of a study, I share the changes we are going to make, did make or may need support in making.”

Maintain Agenda Flexibility Components of Vidant SurgiCenter's QAPI agenda might change depend- ing upon the ASC's priorities, Nimmo says. Changes are influenced by new opportunities to improve patient safety, variations in scope of care or clini- cal guidelines, requests by the MEC and completion of goals. “The focus is always on what is required for us to achieve patient safety and quality with a team approach,” she says.

At ROSC, COVID-19 was added to the QAPI agenda early in the pandemic. Its focus has transitioned, Branes says, from stopping elective cases to reopen- ing with restrictions to testing patients and, now, to the impact of the vac- cine. “Healthcare is always evolving, and issues and concerns come and go. My QAPI reports provide awareness of important quality items that are not necessarily the primary focus of our physicians and help them realign focus. Having an MEC willing to discuss next steps and new processes and provide the support that will help bring those to fruition is an asset to any ASC.”


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