Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
CHAPTER 04: QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT 04.01.01 QAPI Plan Frequency of the citation: 31% Overview of the requirement: A written plan, approved by leadership, details the annual quality activities of the ASC. The plan identifies priorities that focus 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 quality indicators and how data will be collected, analyzed, and acted upon. Comment on deficiencies: Surveyors interview leaders and staff and review the written plan to evaluate compliance. Deficiencies were cited for plans that did not include all required elements. Failure to include contracted services and to monitor pain management effectiveness were frequently noted. Examples of ACHC Surveyor findings: ■ The QAPI plan did not address the scope of services provided including contractual services. ■ The QAPI plan lacked reference to monitoring the effectiveness of pain management. ■ The QAPI plan did not incorporate patient satisfaction results. ■ Although the facility is tracking the required elements, they are not specifically identified in the written “Quality Assurance Plan.” ■ The QAPI plan lacked detail of the following: ٝ Specific patient safety Indicators. ٝ How data is collected. ٝ How frequently data is collected. ٝ Evidence of data analysis.
■ Three of ten files that had gone through the credentialing/approval process lacked required elements: ٝ One was granted privileges before the requested AMA profile was provided. ٝ One lacked a criminal background check. ٝ One lacked professional reference reports. ٝ Three lacked OIG reports. ٝ Three lacked evidence of current competence, clinical activity, procedural logs or peer review activities. ٝ Three lacked signed attestations to comply with medical staff bylaws. ٝ Three lacked letters from the governing body granting privileges. ■ Letters indicating approval of privileges by the governing body were signed by the nurse manager rather than a representative of that body. ■ Letters granting privileges lacked the duration of the privileges.
Compliance tips for:
Five elements are the minimum requirement for a complete credentialing file: 1. Verification of education, licensure, certification, etc. 2. Procedural logs, peer reviews, and/or other evidence of current competence. 3. Evidence of reappraisal prior to renewal of privileges. 4. Governing body review of recommendations from professional staff regarding each applicant. 5. A letter granting, denying, or adjusting the scope and duration of privileges. ■ Audit files for inclusion of required elements. ■ Cross reference privileges requested with privileges granted/delineation of privileges. ■ Define a step-by-step process for credentialing and privileging. ■ The governing body’s responsibility for the quality of care provided the ASC makes the credentialing and privileging process extremely important. Do not advance incomplete applications for review.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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