How to Make Your QAPI Data Count
By Cyndi Newman, MSHL, BSN, RN, Clinical Review Specialist
Ambulatory surgery centers (ASCs) are healthcare facilities that offer patients an alternative to having surgery in the hospital setting. An important aspect of being able to provide these services in a safe and effective manner is the center’s Quality Assessment and Performance Improvement (QAPI) program.
Today, much emphasis is being placed on providing quality health care at reduced cost and providing consumers with choices based on reported quality data.
As part of the Centers for Medicare & Medicaid Services (CMS) Outpatient Prospective Payment System (OPPS)/ASC final rule in 2012, CMS develops quality measures for organizations to report data through the Ambulatory Surgical Center Quality Reporting (ASCQR) Program. The payment determinations measures for calendar year 2022 focus on intraoperative and post-operative care and include:
- ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients.
- ASC-11 Cataracts: Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery.
- ASC-12 Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy.
- ASC-13 Normothermia.
- ASC-14 Unplanned Anterior Vitrectomy.
- ASC-17 Hospital Visits After Orthopedic Ambulatory Surgical Center Procedures.
- ASC-18 Hospital Visits After Urology Ambulatory Surgical Center Procedures.
Consider these measures and the ACHC QAPI requirements when creating your annual QAPI plan.
Standard 04.00.01 Quality Assessment and Performance Improvement
The ASC must develop, implement, and maintain an ongoing, data-driven
Quality Assessment Performance Improvement (QAPI) program.
The QAPI Conditions for Coverage (CfC) require an ambulatory surgery center (ASC) to take a proactive, comprehensive, and ongoing approach to improving the quality and safety of the surgical services it delivers.
The QAPI CfC presumes that the ASC employ a systems approach to:
- Evaluating systems and processes.
- Identifying problems that have occurred or that potentially might result from the ASC’s practices.
- Getting to root causes of problems rather than just superficially addressing one problem at a time.
Standard 04.00.03 Measure, Analyze, and Track Quality Indicators
The ASC must measure, analyze, and track quality indicators, adverse patient events, infection control, and other aspects of performance that include care and services furnished in the ASC.
- ASCs must track all patient adverse events in order to determine through subsequent analysis whether the events were the results of errors that should have been preventable to reduce the likelihood of such events in the future.
- ASCs are also expected to identify errors that result in near misses, since such errors have the potential to cause future adverse events.
Standard 04.00.04 Quality Program Data
The program must incorporate quality indicator data including patient care and other relevant data regarding services furnished in the ASC.
The ASC must not only identify a number of indicators or measures of quality and patient safety but also actively collect data related to those measures at the intervals called for by its QAPI program.
Standard 04.00.06 Program Activities: Set Priorities
The ASC must set priorities for its performance improvement activities
that:
- Focus on high-risk, high-volume, and problem-prone areas.
- Consider incidence, prevalence, and severity of problems in those areas.
- Affect health outcomes, patient safety, and quality of care.
Tips for Compliance
- Recognize that QAPI programs work best in an environment that fixes problems rather than assigning blame.
- Keep the program continuous, not just a one-time effort.
- Evidence of this would include, but not be limited to, collection of quality data at regular intervals; analysis of the updated data at regular intervals; records of actions taken to address quality problems identified in the analyses; and new data collection to determine if the corrective actions were effective.
- Choose indicators that are associated with improvement in patient health outcomes and safety.
- Indicators should include all patient care services and contracted services provided at the ASC.
- Understand the rationale used for selecting the particular indicators an ASC has chosen to track.
- Set priorities for performance improvement (PI) projects and outline them in your QAPI plan.
- Ensure that quality data is submitted at least quarterly for all services.
- Keep staff involved in QAPI and PI projects.
Ambulatory surgery centers have done a fantastic job of providing safe and effective surgical care in the out-patient setting for decades. Dedication to the organization’s QAPI program ensures this will continue for decades to come.
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