Transcript PHAM Contributors Meeting

2013 Update for ASC
Governing Body
QAPI
California Department of Public Health
2013 Update
• Many facilities now being re-surveyed on
the CMS 3 year schedule
• Pleased to report that a significant number
of those facilities have demonstrated
marked improvement and compliance
• Reviewed Policies & Procedures have
been updated and corrected
2013 Update
• An ASC by any other name is still a
surgical facility, first and foremost
• This means the facility must meet all
applicable State and Federal regulations
concerning operating room environments
Governing Body
Governing Body
• The ASC must have a GB that assumes
full legal responsibility for determining,
implementing, and monitoring policies
governing the ASC’s total operation.
• The GB has oversight and accountability
for the quality assessment and
performance improvement program
(QAPI)
Governing Body
• Policies must be effective and compliant
• GB responsibilities are closely tied to the
requirements under Medical Staff, QAPI,
and Patient Rights
• CMS is stressing in the new regulations
that the GB is completely responsible for
the QAPI program and its implementation
Governing Body
• Specific responsibilities include:
– Adopting formal P&P that govern all
operations within the ASC
– Direct oversight and accountability for the
QAPI program
– Ensure the overall quality of the ASC’s
healthcare services
– Ensure a safe environment for all care
– Develop & maintain a disaster preparedness
plan
Governing Body
• The GB may delegate certain day-to-day
operational responsibilities
– To administrative, medical, and support
personnel
– Must retain overall responsibility
– Delegations must be documented in writing
Governing Body
• Important to recognize that deficiencies
noted under the QAPI tag may well result
in citation under the GB tags as well
• Similar situation for “safe environment”
Governing Body
• When services are provided through a
contract with an outside resource, the ASC
must assure that these services are
provided in a safe and effective manner.
• GB oversight includes following the
performance of these contracts under the
QAPI program
Governing Body
• The ASC must have an effective
procedure for the immediate transfer to a
hospital of patients requiring emergency
medical care beyond the capabilities of the
ASC
Governing Body
• The ASC must:
– Have a written transfer agreement with that
hospital
– Ensure that all physicians performing surgery
at the ASC have admitting privileges at an
available hospital
– Stabilize and provide emergency care for a
patient awaiting such transportation
– Take necessary steps to arrange admission
for patient to hospital
Governing Body
• The ASC must maintain a written disaster
preparedness plan which provides for the
emergency care of patients, staff, and
others in the facility, in the event of fire,
natural disaster, or other unexpected
events or circumstances that are likely to
threaten the health and safety of those in
the ASC
Governing Body
• The ASC should conduct at least yearly
disaster drills to test the plan’s
effectiveness
• The ASC should maintain a written
evaluation of each drill and promptly
correct any corrections needed
QAPI
QAPI
• The ASC must develop, implement, and
maintain an ongoing, data-driven quality
assessment and performance
improvement (QAPI) program.
QAPI
• QAPI must include an ongoing program
that demonstrates measurable
improvement in patient health outcomes,
as well as uses quality indicators or
performance measures associated with
improved health outcomes and reduction
of medical errors.
– Focus on process rather than specific issues
QAPI
• The program must measure, analyze,
and track quality indicators, adverse
patient events, infection control, and
other aspects of performance covering
care and services furnished in the
ASC
QAPI
• Types and Examples of Quality Indicators
– Outcomes: results of care, HAI rates,
complications, hospital transfers and cases
requiring over 24 hours of care
– Process of care: checking on how often welldefined processes such as antibiotic
prophylaxis before surgery are carried out
– Patient perceptions of care received
QAPI
• ASC’s performance improvement activities
must focus on areas with most impact:
– High risk areas
– High volume procedures
– Problem-prone areas
Consider the following 3 areas:
1.Incidence
2.Prevalence
3.Severity
QAPI
• Examples of quality indicators include:
– Patient burns
– Patient falls
– Hospital transfers
– Wrong site surgeries
– Use of prophylactic IV antibiotics and timing in
relation to the procedure
QAPI
• ASCs must:
– Identify and reduce medical errors
• Failure of planned action to be completed as
intended, or using a wrong plan to achieve an aim
– Measure and analyze adverse patient events
• Errors don’t necessarily have to result in patient
harm
• Adverse event which is due to an error is
“preventable”
QAPI
• Some examples of adverse events are:
– Patient burns due to surgical fire
– Transfer to an acute care facility
– Patient fall
– Wrong site or procedure
– Retained instruments or sponges
– Surgical site infection
QAPI
• ASC must track all adverse patient events
to determine:
– Whether they were due to an error and could
be preventable
– How to reduce the likelihood of recurrence
QAPI
• Based upon that analysis, ASC must
implement corrective actions which are
likely to reduce medical errors and
adverse patient events
• Must monitor the corrective actions to see
if improvement occurs
QAPI
• Each ASC must undertake performance
improvement projects each year:
– Activities should correlate to issues or
problems identified
– Must document showing:
• Why project was chosen
• What data was collected and why
• What evidence that project will lead to
improvement (i.e. a national standard)
• Show current status of project
QAPI
• The Governing Body is responsible to
ensure that the QAPI program:
– Is defined, implemented, and maintained
– Specifies data collection methods, frequency,
and details
– Evaluate all improvements for effectiveness
– Clearly establish expectations for safety
– Have enough staff, time, and information
systems, as well as training, to implement the
QAPI program