Volume 2024 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
CHAPTER 04: QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT 04.01.01 QAPI Plan Overview of the requirement:
n Letters granting privileges were dated earlier than the NPDB, OIG, and AMA profiles, indicating that these verifications were not used In the process of granting privileges. n One reappointment file included an expired medical license. n Two credentialing files approved privileges that were not performed at the ASC, indicating a reliance on credentialing at another organization. n Files indicated that privileges had expired prior to completion of the reappointment process. n Reappraisal documentation lacked documentation of peer review including post- surgical transfers, surgical site infections, and other complications. n Credentialing files indicated reappointment for several providers for whom there was no evidence of meeting the minimum number of procedures for reappointment, per medical staff bylaws. n Review relevant ASC policies annually to ensure that all required items are listed and use this to develop a checklist of all items required for privileges to be granted. Identify contacts for credential verification (CVO), if used, and for background checks. n Do not advance requests to the governing body until all required elements are available for review. n Track expiration dates for medical staff licenses, privileges, etc., through a calendar event and issue renewal reminders. ASCs may not rely on another organization’s credentialing and privileging. If a physician provides surgical services at a hospital and at an ASC, the ASC must independently verify credentials and grant privileges based on its own scope of service. When a parent organization operates multiple ASCs, one credentialing process is acceptable, if the approved privileges are specific to all locations for they are approved.
A program to assess quality and complete activities designed to improve performance is developed and implemented. The overall program focuses on high-risk, high-volume, and problem-prone areas with the goal of achieving improvements to patient safety and quality of care. A plan defines what quality measures will be used and how data will be collected, analyzed, and acted upon. Compliance is assessed through staff interviews and document review. Most citations resulted from lack of adequate specificity in defining the plan or failure to identify performance indicators for all areas of the ASC, including contracted services.
Comment on deficiencies:
Frequency of citation:
23%
Tips for compliance:
Examples of surveyor findings:
n The organization’s QAPI Plan lists high-volume, high-risk procedures that are not performed at the ASC. n The plan lacked quality indicators for contracted services. n The plan did not define the collection of indicator data (what data, method and frequency of collection), its analysis, or the process for implementing corrective action and evaluating its effectiveness. n Your QAPI program is a collection of individual plans addressing each area/ department/team in the ASC. n Rather than trying to begin by defining quality measures for each area, start by auditing the data you are currently collecting. Categorize it by service and make sure all areas of the ASC are included. n Identify goals for each measure. Trending your data over time establishes internal benchmarks and researching national industry norms can provide external benchmarks. Use these to create your goals. n Where current performance falls short of the goal, you have an opportunity for improvement. Prioritize action in those areas where risk, volume, incidence, prevalence, or severity are high. Select quality improvement activities with potential for positive impact on patient safety or quality of care. n Implement change incrementally. Simultaneous changes will make it difficult to identify the driver of improvement. n Remeasure after corrective action to assess effectiveness.
Tips for compliance:
Quality improvement is the primary goal of accreditation.
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