Transcript QA Presentation 3-19-14 - Surgery Center Coalition
“Quality Program for
Surgery Centers
Marcy
Sasso
, CASC
The Objective of this Presentation is to Describe:
• • • • • • What A Quality Program Entails Areas of Quality Measurement Methods of Data Collection Implementation Tying in Benchmarking to your QA Program GAIN CONFIDENCE in your QUALITY Program
Quality Program- It’s a Name
•
Quality Assurance QA
•
Quality Improvement QI
•
Performance Improvement PI
•
Quality Assurance Performance Improvement QAPI
•
Total Quality Management TQM
Elements of Your Quality Program
From The Booking Form Pre-op Phone Call Patient Registration Pre-op Assessment Consents Medical Record Documentation Time- Out Recovery To The Post-op Phone Call
Quality Indicators… Just a FEW
Infection Control Volume and Procedure Statistics Occurrence Reports Procedure Complications Sedation/Anesthesia Complications Turnover Rate Cancellation Rates Scope Reprocessing BBP Exposures Specimen Errors Logs Patient Wait Times Staffing Levels Start Times Safe Injection Practices Poor Preps
Continual Quality Examples
Contracts Patient Satisfaction Peer Review Minutes * Education *Document all QA Activity Preventative Maintenance Chart Audits Credentialing Quarterly Meetings In-Services
Drills, Safety & Rounds
Malignant Hyperthermia- General Anesthesia Fire, With Scenario, And Transmission Form Disaster, With Scenario Code Blue Fire Extinguishers, Eye Wash, Facility Rounds Annually Quarterly Every 6 months Annually
Why Have a Quality Program Anyway?
It’s REQUIRED for CENTER ACCREDIDATION
TJC AAAHC AAAASF Medicare- CMS
To PROVIDE QUALITY PATIENT CARE
CMS Regulations Q-0081 416.43
416.41 The ASC must have a governing body that assumes full legal responsibility for determining, implementing, and monitoring policies governing the ASC's total operation. The governing body has oversight and accountability for the quality assessment and performance improvement program, ensures that facility policies and programs are administered so as to provide quality health care in a safe environment, and develops and maintains a disaster preparedness plan.
416.43 (d)(1) Every ASC must undertake one or more specific quality improvement projects each year *416.43 (d)(2) ASC must document the projects being conducted, include analysis and explain actions and results.
The ASC must establish ongoing quality indicators to measure, track, and analyze data collected.
*The QAPI program must include infection control, radiology services and contract services.
Mandatory CMS Reporting
Patient Burn Patient Fall Appropriate Hair Removal Hospital Transfer / Admission Prophylactic Antibiotic Timing Wrong Site, Side, Patient, Procedure Or Implant ASCs that fail to successfully report will face a 2% facility fee reduction in future year's rates
Safe Surgery Checklist
ASC-6 Assess whether an ASC uses a safe surgery checklist May employ any checklist as long as it addresses effective communication and safe surgery practices in each of three peri-operative periods:
Prior to administering anesthesia,
Prior to incision, and
Prior to the patient leaving the operating room Applies to all ASCs, including GI endoscopy centers Measurement from January 1, 2012 through December 31, 2012 Web Based Reporting via Quality Net
Selected Procedures
ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures* Procedure Category Corresponding HCPCS Codes: Cardio vascular / Eye / Gastrointestinal /Geni to Urinary Musculoskeletal / Nervous System / Respiratory/Skin Reporting via Quality Net (www.qualitynet.org
)
Influenza Vaccination
ASC- 8 Influenza Vaccination Coverage Among Health Care Workers Definitions Pending, But Appears Hcw Will Include: Staff On Facility Payroll, Students And Volunteers Licensed Independent Practitioners, (E.G. Physicians, Advance Practice Nurses And Physician Assistants) Measurement Begins With Immunizations For The Flu Season Oct. 1, 2014 thru March 31, 2015; for CY 2016 payment determination
ASC 9-11 New Reporting
Measures 9-11 Cover Percentages Of Performance On Chart-abstracted Sample Data For Colonoscopies And Cataract Surgeries All Ascs, Regardless Of Specialty Or Case Mix, Will Be Required To Report Them.
April-December 2014 dates of service
How to Begin the Process
Have a Meeting with Your Team
What Is A Problem Area Or Trend You Are Seeing At Your Center And Want To Improve Upon? Are you doing ROUNDS?
Patient Satisfaction
Lower Revenue
Cancellations
Morale
Turnover Times
A dialog Needs to Occur, to Effectively Decide on what Needs to be Studied and Possibly Revised
Ten Step Template
Medical Records
1.
2.
3.
4.
5.
6.
7.
8.
Purpose Identification of the performance goal Description of the data that will be collected Evidence of Data Collection (not the conclusion) Data analysis that describes the findings A comparison of the organizations current performance in the area of study against the previously identified performance goal. 7. Implementation of the corrective actions i.e., interventions, to resolve the identified problem. Re-measurement ( a second round of data collection and analysis) of the problem to determine objectively whether the corrective actions, i.e., interventions, have achieved and sustained demonstrable improvement.
Re-measurement ( a second round of data collection and analysis) of the problem to determine objectively whether the corrective actions, i.e., interventions, have achieved and sustained demonstrable improvement.
9.
10.
If the initial corrective action(s) did not achieve and or sustain the desired improved performance, implementation of additional corrective actions(s) and continued re measurement until the problem is resolved or is no longer relevant Communication of the findings of the quality improvement activities to the governing body and throughout the organization as appropriate, and the findings were incorporated into the organization's educational activities. Administrator/ Director of Nursing ___________________________ Date ______________ Medical Director __________________________________________ Date ______________
# 1 Purpose
Medical Records
Describe The Suspected Problem Or Concern; Why Is It Important For The Center To Address This Problem Complaints Patient Safety Financial Impact
During an audit, medical record charting was substandard and not meeting the requirements of an accurate patient record. Medical Record errors/non-compliance may lead to patient safety issues as well as risk management areas of concern .
#
2 Identification of the Performance Goal
Medical Records
Where Do We Want To Be?
Expected Outcome/Goal: 100% Compliance of the Required Medical Record Elements Actual Outcome: Initial study, TBD
# 3 Description of the Data that will be Collected
Medical Records
A Chart Audit Tool was Developed to Collect Data for Measurement. It was Determined that The Following Areas of the Patient Chart would be Audited. The Audit will be Comprised of the Following Items: • Anesthesia Consent • Anesthesia Orders • Physician Orders • Medication Reconciliation Form • History & Physical
# 4 Evidence of Data Collection
Medical Records
(This is not the conclusion) See Audit Tool for Dates of Collection: Sheet Attached
Spreadsheet, computer reports, audit, or observation
# 5 Data Analysis
Medical Records
Describes the findings, Frequency or Severity of the Problem, how often is it Occurring and Identify the Source of the Problem.
(Initial) 30 Medical Records will be audited by the DON, every month until 100% compliance is reached. After the initial audit it was evident that areas of the records were not 100% compliant. Frequency: The Nurses and Physicians have been inconsistent with accurate documentation of the medical records per policy. Severity: This can lead to miscommunication and patient safety issues regarding timely patient care.
# 6 A Comparison of the Center’s Current Performance
Medical Records
Analyze Your Data
(Initial TBD) Is there an Increase or Decrease ,where?
Do you Note a Trend?
Is this Trend an Outlier or a Pattern?
Are you Using the Same Method to Collect the Data?
# 7 Implementation of the Corrective Actions
Medical Records
What are you Doing to Correct the Problem; Interventions, to Resolve the Identified Problem?
Amend a Policy Re-do Forms In-Services
An in-service was held for staff and physicians about the importance of medical record compliance and accurate “timely” completion. The H&P form was reviewed with Physicians regarding DOS update and specific documentation.
Another medical record audit will occur in 30 days by the DON.
# 8 Re-Measurement
Medical Records
A second round of data collection and analysis of the problem to determine objectively whether the corrective actions, i.e., interventions, have achieved and sustained demonstrable improvement. You may need to repeat this several times until you have reached your desired goal.
(Initial TBD) 1. Use the data collection process you described in Step 4, modify if necessary 2. Use the new data to perform the analyses you described in Step 5.
3. Repeat Step 6 if you haven’t met your goal – You may need to re-think your original goal if applicable.
#9 If You Have Not Met Your Goal
Medical Records
If the initial corrective action(s) did not achieve and or sustain the desired improved performance, implementation of additional corrective actions(s) and continued re measurement until the problem is resolved or is no longer relevant.
(Initial TBD)
What are you doing to reach your goal, that is different than your re-measurement?
Policy Change Counseling New Forms Staffing Change
# 10 Communication of Your Findings
Medical Records
How are you communicating the quality improvement activities with your Governing Body and what recommendations are being made regarding this study? (Are the findings incorporated into the Center’s educational activities and minutes)? The Medical Record Audit study and data collection tool was communicated to the Governing Body. Sub-standard Medical Record documentation is a risk management concern; the Governing Body approved the study and it’s continuation until the anticipated goal is reached.
An Action Plan
If you have a non-measurable subject with evidence of your identification, implementation and outcome, create an
ACTION PLAN
Booking forms getting lost in fax; new dedicated fax line Continuous repairs; change vendor New lock on a door; changed a code
CMS Tags; Deficiencies
“Review of the QA and Governing Body minutes, the Governing Body did not provide leadership and review of the QA program”.
“Review of minutes identified incidents of unusual occurrences had been reported, however no root cause analysis had been completed on the incidents. No evidence was found of an investigation and no interventions were put into place to minimize risks for other patients. The action plan indicated, continue to document".
“The committee indicated this would be followed up on, however, review of minutes from the next meeting identified no documentation of the concern identified, no actions were taken or analysis to determine preventive strategies to promote patient safety”.
CMS Tags; Deficiencies
“Based on interview, review of personnel files, governing body and medical staff bylaws and governing body meeting minutes, the ASC did not assure that medical staff privileges were reappraised every two (2)* years, in accordance with the Governing Body Bylaws and the Medical staff Bylaws”. Findings include: “A review of personnel files lacked any evidence of re-credentialing or reappraisal of medical staff privileges since initially approved by the Governing Body in 2011”.
*Consider re-credentialing every 36 months.
10 Step Study vs Benchmarking
A 10 Step Study is implemented when A Problem or Trend has been Identified in your Center.
Benchmarking is done with Specific Data to Understand where your Center Stands, with Identifiable Areas of Relevance.
What Can You Benchmark?
Everything and Anything that Occurs Within Your Center
Types of Benchmarking
INTERNAL Looking within your Own Center EXTERNAL Comparing with Like Center NATIONAL Comparing with National Center
Internal Benchmarking
• • • • • • Physician to Physician Supply Costs Per Vendor Benefits- Salaries Hand Hygiene Chart Audit Compare Last Years Numbers to Current Numbers
External Benchmarking
• Benchmark with o ther Center’s that are the same Specialty or Size as yours, Because their Best Practices will be more Likely to Work in your Center • It’s an Opportunity to Set Realistic Goals for Improving Performance and your Process • If an Equal Center can Perform at a Certain Level with Best Practices, then so can yours! It Allows you to see if you have an Issue (s) in your Center
National Benchmarking
ASC Quality Collaboration www.ascquality.org
ASCA [email protected]
Clinical Examples
Medication Errors Transfers Infections Narcotic Counts Incorrect Site Delays Physician Late Arrival Turnover Time History and Physicals Falls Burns Re-Admission to OR BBP Occurrence Prolonged PACU Stay Incomplete Colonoscopy Equipment Issues Post-Op Complication Hand Hygiene
Administrative Examples
Op Reports Outside 30 Days Medical Record Audits Total Cases Performed Case Cancellations/ No-Shows Peer Review Employee Injuries Patient Wait Times Patient Satisfaction Return Rate
Financial Examples
Case Costing Per Specialty Per Physician Block Time Utilization Billing Delays Coding AR Days (Per Insurance) Number Of Cases Net Revenue Staffing Costs Per Patient Overtime Dollars
Samples of Benchmarking Reports
• If you are Familiar with EXCEL or POWERPOINT you can Transform your Data into an “Attractive” Visual Report • If you Collect Data Manually, you can Turn it into a Template or Spreadsheet • If you use QUICKBOOKS your Financial Data can be Manipulated into a Report/Graph
Patients Seen Per Quarter 2013
Internal
345 318 322 344 433 499 400 445 400 350 316 300 Q1 Q2 Q3 Q4 Dr. A Dr. B Dr. C
Average AR Days Per Insurance Carrier
Internal
30 20 10 0 60 50 40
2013 2012 23 24 Medicare 31 30 Cigna 44 45 BC/BS 51 43 Aetna
100 80 60 40 20 0
Hand Hygiene Monitoring
Internal
78 May 1, 2013 - May 31, 2013 96 66 Surgeons Nurses Anesthesiologists 89 Techs
Patient Hospital Transfers
Internal
2 1 0 5 4 3 5 Q1 2 5 3 Q2 1 Q3 1 2 Q4 4 2013 2012
Q2 Patient Survey Return Rates
External
81% 59% 58% 34% 29% 23% 24% 16% 13% NJ234 NJ121 NJ355 NJ388 NJ790 NJ289 NJ122 NJ277 National Rate
Calendar of 2014 ASC Studies Sasso Consulting, LLC
Registration Fee
□ $ 150.00
Data Collection Period
Q 1 Jan 1 - March 31
Name of Benchmark Study Occurrences
(needlesticks/sharps, PT transfer, fall, visitor injury, re-admit to OR, equipment failure) □ □ □ □ □ □ $ 150.00
$ 150.00 $ 150.00
$ 150.00 $ 150.00 $ 150.00
Mini 1
Feb 1 - March 31 Q 2 April - June 30
Mini 2
May 1 - June 30 Q 3 July 1 - Sept 30
Mini 3
Sept 1 - Oct 31 Q 4 Oct 1 - Dec 31
Case Costing
□
EGD (w/o biopsy)
□
Lumbar Epidural □ Cataract
(select one) Cancellations
(within 48 hours of procedure does not include re-scheduled cases )
Patient Satisfaction Returns Medical Record Audit
(H&P, Pre-Op / PACU Orders, Discharge Order, OP report, Medication Reconciliation)
□ GI Specific or □ Ophthalmic Specific Billing
(Delays, Claim Denials, AR days)
□ in network □ out of network □ both in and out of network
Amount enclosed $ __________ # Programs ______
Sign up for 4 or more studies and receive a complimentary QA Excel data collection tool ++ Customized Excel templates will be sent via email 2 weeks prior to start of each registered study collection period. Data Collection Due Date
April 15 April 15 July 15 July15 October 15 Nov 15 Jan 15, 2015
Websites with Additional Information
ASC Quality Collaboration website http://ascqua;ity.org/qua;itymeasurers.cfm
Ambulatory Surgery Center Association (ASCA) www.ascassociation.org
CMS ASC Center www.cms.gov/center/asc.asp
Quality Net website (CMS Specifications Manual) www.qualitynet.org
Contact Information
Marcy Sasso, CASC
(862) 812-5611 Madison, NJ 07940 For Additional Information
Thank You for Participating in “Quality For your Surgical Center”