Quality: Inside 2023 Performance Improvement Studies


Regulators cited many deficiencies in facilities’ projects.

The calendar says 2024 — and that means the start of a new year of performance improvement projects. You know, those multiple continuous initiatives during which you make steady improvements by identifying gaps or issues, creating and implementing solutions, and monitoring for ongoing success.

Spotting missed steps

Many ASC leaders, however, find that while they improve upon the outcome-based measures upon which the improvement projects are based, they often miss closing the loop on parts of the plan because of inadequate documentation and thorough reporting of the projects. These missed steps are a prime source of deficiencies. In fact, 20% of facilities surveyed by the Accreditation Association for Ambulatory Health Care (AAAHC) were rated as less than fully compliant with quality management and performance improvement requirements, according to its Quality Roadmap of 2023. I’ll evaluate a sample performance improvement study to see how well it meets the requirements for success.

• A review of the regulatory and accreditation requirements shows many common elements. Failing to accomplish these are the most commonly cited deficiencies in surveys.

• After data collection during a quality improvement (QI) study shows that an improvement in an area is or may be warranted, an organization must show that continued improvement is taking place. The documentation of the studies should show that the relevant components for improvement have been taking place.

• The amount and scope of separate improvement projects conducted annually must reflect the scope and complexity of the ASC’s services and operations. At least one current quality improvement study should demonstrate that improvement has occurred and been sustained.

• The process should include mechanisms that ensure the results of quality improvement activities are reported throughout the organization, including its governing body.

A sample case analysis

Let’s review an example. The issue was delayed starts in the first cases of the day and the initial data review revealed that timely delivery of processed surgical instruments was likely a major contributor to the problem. Staff then delved into occurrence reports, held conversations with key stakeholders and discussed the rising number of first-case delays with the surgical team during daily huddles.

Obvious — and easily fixable — contributing factors were immediately discovered. The sterile processing department (SPD) staff started their shifts at 6 a.m., which does not provide sufficient time for them to start the machines, run diagnostic tests and process loads in time to have instrument sets ready for the first cases of the day. The process also included the practice of transporting most instruments to the decontamination area at the end of the previous day, after the scheduled shifts of the sterile processing technicians had ended. The SPD techs would either work overtime that night to do the entire job, or the instruments were decontaminated in the evening and left for sterilization that would occur the next day. The SPD staff were included in the brainstorming sessions, and they provided suggestions for schedule changes, including moving a full-time employee to an evening shift from Sunday to Thursday — and improvements were noticed immediately. That relatively simple fix eliminated a significant percentage of the delays and the lowered levels of stress and increased morale among the staff was palpable. Conflicts between the OR and SPD teams surrounding the causes of the delayed case starts went away as well.

This is a clear example of a performance improvement project that demonstrated measurable improvements. In my experience with surveyors, I think this study would fit the bill for approval. It included a precise description of the problem that existed to explain why the project was implemented; a detailed summary of the project results; a clear demonstration that the improvements that occurred have continued; and evidence that the results are part of your organization’s quality assurance and performance improvement plan — and that the plan has been shared with all staff and facility leadership.

The only things that would prevent this performance improvement study from passing a survey would be if it was not presented as a living document that shows ongoing success everyone is aware of. Remember, your performance improvement projects don’t need to be elaborate. In fact, you’re likely making improvements in multiple areas on a daily basis already. Take credit by documenting your steps and sharing the results. For more help getting survey-ready, visit aorn.us/asc_guides to get information about our ASC Academy: A Guide to Quality and Risk Management. OSM

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