QAPI: THE FUTURE OF REPORTING QUALITY CARE TO THE DIFFERENT

AGENCIES THAT GOVERN OUR PRACTICE

Beverly Kirchner, RN, BSN, CNOR, CASCSeptember 2010

Objectives

1) Discuss the new standards on quality reporting for CMS in a surgery center

2) Discuss the ASC Quality Collaboration work completed and approved by NQF for surgery centers.

3) Describe a QAPI plan that meets the accrediting bodies requirements.

4) Describe the future of quality care and reporting.

Brief Overview of Agencies that Govern ASC’s

CMS State OSHA CDC NFPA NQF Accrediting Organizations

416.41 Governing Body and Management

Must have Governing Body Assumes full legal responsibility for operation of

center Oversight & accountability

Quality Assessment Performance Improvement

Ensures polices & programs are followed Ensures the center provides quality care in a

safe environment

416.41 Governing Body and Management Continued

Oversees contracted services Transfer agreement

Written Hospital CMS Certified

Assures all physicians & allied health staff have: Education Privileges Peer Review Utilization review

Assures physicians have admitting privileges at a hospital that is CMS certified

416.41 Governing Body and Management Continued

Disaster Plan Addresses care for patient & staff Addresses any event that could threaten the

health and safety of anyone in the center Coordinates plan with state & local authorities Conducts drills at least annually

Governance Organizational Chart

Medical Executive Committee

BOARD

Administrator

Business Office

Manager

Director of Nurses

Committee Organizational Chart

BOARD

MEC

Administrator

QAPI Committee

Safety Officer

Infection

Control

Pharmacy Employee Health

Nursing Care

Committee

Radiation Safety

416.42 Quality Assessment & Performance Improvement

Develop Implement Maintain ongoing program Data driven Demonstrates measurable improvement

416.42 Quality Assessment & Performance Improvement Continued

Center Must Measure Analyze Track quality indicators Adverse patient events Infection Control Data must be used to monitor effectiveness & safety of

services provided Identify opportunities for improvement Focus on high risk, high volume, problem-prone areas Number of scope projects conducted annually must

reflect complexity of ASC’s services

416.42 Quality Assessment & Performance Improvement Continued

Documentation Reason Description Specifies data collection method, frequency &

details Center must allow sufficient staff

Time Information Systems Training & education

ASC Quality Collaboration

ASC Quality Collaboration Formed in 2006 Focus: on healthcare quality & safety

Today’s Focus Measure development Public Reporting of Quality Data Advancing ASC Quality Advocacy

National Quality Forum Endorsed Measures

Patient Fall Patient Burn Hospital Transfer/Admission Wrong Site, Side, Patient Procedure, Implant Prophyloctic IV Antibiotic Timing Appropriate Surgical Site Hair Removal

The ASC Quality Collaboration is dedicated to advancing

high quality, patient-centered care in ambulatory surgery

centers.

How are we doing?

Rate of patient fall in the ASC 0.149 per 1000 admission

Represents the experience of 1,278,879 ASC admissions seen 1,130 facilities between January 1 and March 31, 2010

Rate of Patient Burns: 0.037 per 1000 Admission

Represents the experience of 1,275,578, ASC admissions seen in 1,123 facilities between January 1 and March 31, 2010.

Rate of Hospital/Admissions: 1.081 per 1000 admissions

Represents the experience of 1,334,614 ASC admissions seen in 1,185 facilities between January 1 and March 31, 2010.

Wrong Site, Side, Patient, Implant events: 0.034 per 1000 admissions

Represents the experience of 1,308,530 ASC admissions seen in 1,169 facilities between January 1 and March 31, 2010.

Percentage of ASC admissions with Antibiotics ordered who received antibiotics on time: 95%

Represents the experience of 692,129 ASC admissions seen in 674 facilities between January 1 and March 31, 2010.

ASC Tools for Infection Prevention

Hand Hygiene Safe Injection Practice Point of Care Devices

Future Tool Kit Environment of Care

Website: ASC Quality.org Last accessed: August 23,2010

Elements of an ASC QAPI Plan

Mission Statement components: Direct activities concerning design of new services Monitor processes Assess processes Measure quality of care

Patient satisfaction Peer review Service Patient outcomes

Look for opportunities to improve

Elements of an ASC QAPI Plan

Program Plan components: Discuss ongoing process Discuss responsibility of Board Discuss responsibility of Committee Discuss reporting system in the facility

Purpose: To provide service excellence, and the improvement of patient outcomes and processes by acting on opportunities for increment performance improvement.

Elements of an ASC QAPI Plan

Leadership Responsibilities: Set expectations Manage processes Set priorities to measure Improve the quality of:

Governance /Education Management/ Education Clinical care/ Education Patient care Support activities

Safety Risk management Infection prevention

Elements of an ASC QAPI Plan

Design of approach to improving process Design of processes Provide resources Implementation of performance processes Follow-up on performance processes

Assess if there is improvement How effective is the improvement

Quality Assessment: Performance Improvement Committee

Members include: Chair Anesthesia provider Surgeon Center administrator or clinical coordinator Staff members

OR Admission PACU Infection Preventionist Safety Officer Risk Manager Business office

Quality Assessment Performance Improvement Committee Responsibilities:

Review Process deficiencies Problems Failures User error

Select and prioritize improvement opportunities Identify resource needed for a project Request resources from the Governing Board through

Leadership team Create PI project design

Complete an assessment of potential problem Research issue Develop goals Design tool for data collection

Quality Assessment Performance Improvement Committee Responsibilities Continued:

Determine expected outcome to measure Implement change

Obtain Governing Board approval Educate staff

Reporting results

The Chair of the Quality Assessment Improvement Committee is

responsible for providing program support to the staff and leadership.

Quality Assessment Performance Improvement Committee’s work and reports

are ongoing.

Establish a calendar for meetings Establish a schedule/agenda on what is

reported at each meeting Prepare a quarterly report of all activities to be

presented to the Medical Executive Committee and Governing Board

QAPI documents are kept confidential

Example of QAPI Meeting Calendar

Month Aspect of Care/Service

Responsible Reporter

Appropriateness of Care/Benchmarks

Administrator

JANUARY Occurrence/Variance Reports for opportunities for process improvement

Administrator

Risk Management Report Risk Manager or Administrator

Environment of Care-Safety Safety Officer

Medication Process Pharmacy Nurse & Pharmacy Consultant

FEBRUARY Clinical Process Clinical Coordinator or Administrator

Business Office Process Business Office Manager or Designee

Infection Prevention Infection Preventionist

MARCH Employee Health Employee Health Nurse

Patient Satisfaction Administrator

Other projects Chair QAPI

QAPI Committee Reports Organization Wide to

Annual Medical Staff Meeting Quarterly Medical Executive Committee Quarterly to the Governing Board Monthly at Staff Meeting

QAPI Committee Reports outside of Committee meeting do not include the Names of patient, provider, or employee

Only QAPI Committee Members are given identifying information. Only committee members can attend meeting.

Successful QAPI Programs

Encourage staff participation & support program

Encourage medical staff participation & support program

Provide easy ways to make suggestions or communicate process problems identified

Medical Executive Committee and Governing Board support the program

Leadership supports the program

Developing a Performance Improvement Program/Project

Resources Budget dollars for resources needed Obtain approval Governing Board

Program Program/Project selection should be important to the

organization Doing the right thing Doing the right thing well

Patient & Organization Focused Patient or organizational rights Patient assessment Patient rights Educational Continuity of care Improving organization performance

Developing a Performance Improvement Program/Project Continued

Improve Leadership Manage Environment Manage Human Resources Manage Information Prevention Safety

Program Should Reflect

Organizational Mission and Vision Be collaborative with different services Support for organization Meet the needs of the organization

Program/ Project Should Identify

Dimensions of performance that will be most affected

Improved performance goal or goals How the team will determine if new process is

performing the way the team anticipated Who will work on the program/project

Program/Project Data Collection & Performance

Focus on process or outcome Provide base data Identify opportunity for improvement Create process redesign Collect data –ongoing Re-evaluate –make changes if needed

Program/Project Assessment

Compare past performance with standards, policy, Best Practices

Monitoring is ongoing Focus intense assessment on:

Major discrepancies between pre & post-op Confirm medication, transfusions or any other

unexpected reactions Review all medication errors Any unexpected event or outcome

Quality Assessment Performance Improvement Committee will

oversee the review and revision of the center’s policies and procedures annually.

Unplanned Hypothermic Event

Name of Measure Unplanned Hypothermic Event

Measure Type OutcomeIntent To capture the number of admissions (patients) who receive a preadmission

assessment for risk of hypothermic event during invasive procedure and have approved interventions utlized to prevent an unplanned hypothermic event and still experiences a hypothermic event.

Numerator/Denominator Numerator: Ambulatory Surgery Center (ASC) admissions experiencing an unplanned hypothermic event detected by temperature monitoring throughout patient stay.Denominator: All ASC admissions who have a procedure performed.

Inclusions/Exclusions Numerator: Ambulatory Surgery Center (ASC) admissions experiencing an unplanned hypothermic event detected by temperature monitoring throughout patient stay.Numerator Exclusions: NoneDenominator Inclusions: All ASC admissions who have a procedure performed.

Denominator Exclusions: Admissions who upon being admitted to the ASC are experiencing a hypothermic event.

Data Sources ASC operational data including but not limited to adminsitrative records, medical records, and follow up, all quality management data related to the patient's unplanned hypothermic event and post op calls from patients or physician offices.   

Definitions Admission: completion of registration upon entry into the facility; Allowable values: The count for this data element would be represented by any whole number 0 or greaterUnintended hypothermia: any core temperature below 36 degree C or 96.8 degrees F . Inadvertent hypothermia: any core temperature less than 36 degrees C or 96.8 degrees FDischarge: occurs when the patient leaves the confines of the ASC

Monitoring Unplanned Hypothermia Events

Quality Assurance Project

Purpose: To develop a standardized process in which unplanned hypothermic events occur in

less than five (5) percent of patients undergoing an invasive procedure in the center.

Background/Significance•It is estimated that 50% to 90% of patients undergoing a surgical procedure will experience a hypothermic event. •An unplanned hypothermic event is preventable. •Hypothermia is defined as a core temperature below 36°C (96.8 °F) •Vasoconstriction occurs during a hypothermic event •Vasoconstriction:

-Reduces flow of nutrients to the body -Decreases oxygen delivery

-Inadvently alters wound healing - neurophils / (white blood cells) can't function at optimum

levels

•Perioperative challenges that effect normothermia in a patient:- low ambient room temperatures - patients admission anxiety level- irrigation fluid - IV fluid - Size of skin exposure to room temperature - Prep solutions - Length of surgery - Blood and fluid loss - Anesthesia/anesthesia gases

•Patients at risk for unplanned hypothermic event include:- neonates -older adults

-females -fluid shifts in patient-peripheral vascular disease-cardiovascular disease-endocrine disorders -open wounds -Renal disease •Unplanned hypothermic events affect body systems -Respiratory -Cardiovascular -Adrenergic and immune systems -Alter medication metabolism-Variations in electrolyte levels

•General and regional anesthesia affect core body temperature •Affected ways to decrease risk of an unplanned hypothermia event:

-maintain admission temperature -adequate pain control -hydration-increase ambient room temperature -provide warm blankets-provide warm IV fluid -provide warm Irrigation fluid -humidified and warm anesthesia gases -forced air warming

Tracking Design: Typical Descriptive Study

Phenomenon of Interest Measurement Descriptive Interpretation Hypothesis

Prevention of Unplanned Hypothermia Event Audit Tool Interactive Care Plan & Clinical Pathway 95% Compliance

Method: PDCA Method -Problem: Interventions for unplanned hypothermia are not followed on every patient.-Opportunity: Improve communication (verbal & written) between pre-admission nurse and admission nurseImprove patient satisfaction by

-Educate staff the affects of hypothermia on the patients outcome

-Review on organizational policy

- Review organizational interventions

Patient Flow for Prevention of Unplanned Hypothermia

Patient is scheduled

For SurgeryPreadmission nurse

completes pre-admission nursing

assessment.

Preadmission Nurse plan to patient’s

meddevelops patient care plan and attaches

ical records. Admission nurse further

assesses patient by taking vital signs and initiates interventions

for preventing unplanned hypothermia based on risk analysis.

Admission nurse performs patient care hand off to operating

room circulator.

OR Circulator communicates to OR Team during 1st time

out the risk the patient has for unplanned

hypothermia event and interventions started

based on clinical Pathway and Care Plan.

OR Circulator adds protocols and

interventions the surgeon and or

anesthesia provider request.

OR Circulator and anesthesia provider

performs patient care hand-off with PACU Nurse. PACU Nurse

measures temperature. If patient is hypothermic surgeon and anesthesia provider are notified.

PACU nurse performs patient care hand-off with Discharge nurse

following center policy.

Discharge nurse re-enforces post-op

education to patient and patient's care giver.

Patient care hand-off is performed between

discharge nurse and care giver.

Post-op follow up is completed by center's

staff.

Preadmission Nurse develops patient care plan and attaches plan

to patient’s medical records.

Method: PDCA Model DO

-Develop tracking tool unplanned hypothermic events

-Review data from chart -Review data from chart-Review data from unplanned hypothermic QA

worksheet -Review interventions for effectives -Review findings with: QAPI Committee, Infection

Preventionist, Staff, Leadership Team, Medical Executive Committee, and Board

Unplanned Hypothermia Audit Tool Unplanned Hypothermia includes up-to-date information regarding patient's history, risk level for unplanned hypothermic event, condition, care and interventions.To be completed if patient experiences an unplanned hypothermic event

MR# Did Pre-Admission assessment identify risk for unplanned

hypothermic event?

Were appropriate interventions

accomplished?

Initial Core Temperature

Core Temperature Unplanned

Hypothermic event was noticed

Length of time to get temp back to normothermic

Risk level of Patient

Comments

Yes No N/A Yes No N/A

Method: PDCA Model Check

-Audit medical record of every patient in extreme age groups to assess risk analysis

-Use Audit tool to record unplanned hypothermia events

-Asses staff’s level of understanding of process

-Assess staff’s compliance with policy -Assess staff’s understanding of risk

associated with

Impact Expected

- Supports a culture of safety- Ongoing monitoring is in place to identify

patient risk for unplanned hypothermic- Increase staff understanding of the

dangers to the patient associated with unplanned hypothermia

- Increase staff competency - Increase patient satisfaction

Dissemination of Results to

- Staff - QAPI Committee- Leadership Team - Medical Executive Committee - Board

The Patient Protection & Affordable Care Act Signed in the spring by President Obama Requires

CMS to work with stackholders in the ASC industry and develop a value based purchasing (VBP) System.

Where is ASC Industry Wanting to take Quality Assessment Performance Improvement

1) In favor of developing a value-based purchasing system.

2) Voluntary data collection should start and be followed with public disclosure of quality information.

3) Performance should be measured first within ASC using quality indicators

4)CMS should measure same quality indicators in free-standing surgery centers and hospital out patient departments so the public has apples to apples comparison.

5) Increased Medicare payments should be associated with high performing centers in which there is significant quality

6) Recommend CMS do a share savings plan with centers who perform high quality care and produce savings for Medicare program.

7) Support a program that created competition based on quality and efficiency, drive improvement in care, and improves transparency.

References

Department Health & Human Services, Centers for Medicare and Medicaid Services, State Operations Manual, Appendix L- Guidance for Surveyors: Ambulatory Surgery Centers.

AORN Recommended Practices ASC Quality Collaboration: ASC Quality.org Outpatient Surgery.net> August 2010> ASC

Industry urges CMS to Base Payments on Last accessed 8-24-2010

References

1. Mahoney CB. The economics of patient warning. Outpatient Surgery. 2005: (6) :55-60.

2. Recommended practices for prevention of unplanned perioperative hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 201:293-306

3. Peterson C, ed. Peroperative Nursing Date Set Rev 3rd ed. Denver, CO: AORN, Inc; 2010.

4. Clinical Practice guideline 1 Clinical Guideline for Prevention of Unplanned Perioperative Hypothermia. In:2008-2010 Standards of Perianesthesia Nursing Practice. Cherry Hill, NJ: ASPAN; 2008-2010:22-29