Quality: Keys to Your Quality Program’s Annual Review

Tips to help time-strapped administrators with a critical task.

Where has this year gone? As our lives get increasingly hectic with all the excitement and stress of the holidays, don’t forget to wrap up your quality plan. Although it’s a bit late to start a full quality program, it’s a great time for a quick review.

Preventing gaps

ASC leaders know the quality plan encompasses nearly everything that takes place in the facility and should be accurately monitored and documented, including continued improvements. The end of the year can be challenging for ASC leaders to meet the increased volume demands, requests for time off and winter illnesses impacting patients and staff alike. It is easy to overlook an annual requirement, so take a quick look before it is too late.

Ensuring that your surgery center consistently complies with its quality plan is not just a regulatory requirement; it’s a commitment to providing the highest standard of care to your patients. Here are a few tips for reviewing the effectiveness of your quality plan and avoiding gaps in activities or reporting.

Quality plan purpose

The purpose of the Quality Assurance and Performance Improvement (QAPI) plan is to create an environment where safety is prioritized and high-quality healthcare services are provided in accordance with the principles of professional practice and ethical conduct. It must include, but not be limited to, an ongoing program that measures, analyzes, and tracks quality indicators, adverse patient events, infection control and other aspects of performance that include care and services furnished in the ASC.

Authority and responsibility

The Governing Body is ultimately responsible and accountable for the quality of care provided, risk management and performance improvement in the organization. The list below provides a sample overview of the annual requirements of the Governing Body. Evidence of completion should be documented in Governing Body meeting minutes. Designate committees and/or individuals responsible for development, implementation and oversight of the QAPI program.

• Receive, review and approve written reports of quality data and outcomes.
• Receive, review and approve performance improvement activities and results of action plans.
• Receive, review and approve the facility policies and procedures.
• Receive, review and approve the annual review of the effectiveness of the QAPI Plan.
• Receive, review and approve all credentialing and privileging activities during the year.

Goals and objectives

A successful QAPI plan should focus on high-risk, high volume and problem-prone areas. Consider how often and how severe problems in those areas occur and how they affect health outcomes, patient safety and quality of care. The plan should specify the number and scope of distinct improvement projects conducted annually that reflects the scope and complexity of the ASC’s services and operations. It should also note how strategies to prevent adverse events were implemented in ways that ensured all staff were familiar with them.

Data collection

The organization should consistently gather information on the quality of care from the following sources: medical record reviews; SSI/complication physician reports; peer review results; patient satisfaction surveys; results of postoperative phone calls; patient complaints; verbal reports from employees, patients, visitors or physicians; variance reports; pharmacy audits and reviews; incident reports forwarded to risk management officials; financial audits; and results of environment of care rounds.

Performance improvement activities

Facilities must track adverse patient events, examine their causes, implement and ensure that improvements are sustained over time. The performance improvement projects should be conducted throughout the year, align with the goals and objectives of the quality plan, and the results should be evaluated and reported throughout the organization.

The documentation of projects, which must include project type, reason for implementation and results, should be conducted throughout the year.

Annual review

Assessing your QAPI each year is an important step to closing the loop on regulatory and accreditation requirements and a good way to enhance the overall quality of care provided at your facility. Your annual review should determine whether goals and objectives were achieved and provide a thorough review of data collection reports and performance improvement activities and their results. This process should identify opportunities for the following year’s quality plan, which should be included when the review is shared with leadership and employees.

ASC administrators and leaders should consider the annual quality review a well-spent investment of their time. Although it’s a requirement, it’s also an opportunity to reflect on the care provided and whether steps to improve things were successful. In my experience, it is much easier to plan the quality activities and reporting for the entire year and divide them into four quarters. At the end of the year, you can combine the activities of the four quarters to create the annual review. If you need guidance developing and reviewing your ASC Quality Plan, AORN’s ASC Academy: A Guide to Quality and Risk Assessment Management can help you navigate this regulatory requirement. Learn more about AORN Ambulatory Solutions at aorn.org/asc. OSM