Develop an Outcomes-based, Survey-proof QAPI Program
The ASC director called in a panic. CMS sent a surveyor, who said the facility would be shut down tomorrow unless they sought immediate help from a consultant.
That scenario happens more times than most people imagine, says John Goehle, MBA, CPA, CASC, chief operating officer of Ambulatory Healthcare Strategies in Rochester, NY.
The smarter ASCs seek help before it gets to that point. They create policies and procedures (P&Ps), train staff on how to follow them, and ask experts to review both written policies and the actions employees take to follow the organization’s P&Ps, Goehle says.
CMS looks for written policies and wants to see proof that managers are teaching employees, and that employees are following those procedures. Healthcare organizations that experience problems with the survey often are plagued by policies that are not well-followed.
At the very least, ASCs should create a quality assurance performance improvement (QAPI) program that tackles the most common problem areas and the low-hanging fruit, he suggests.
The following are Goehle’s suggestions:
• Focus on governance and oversight. “Make sure your governing body is showing appropriate oversight of the operation,” Goehle says.
Red flags occur when organizations don’t conduct enough board meetings or are not documenting in the minutes what happened in those meetings.
“I’m passionate about governance because I’ve seen so many problems with it,” Goehle says. “Ultimately, everything becomes a governance issue. When the nursing staff is not doing handwashing, it’s the governance not overseeing and following up.”
The surveyor’s chief information about how well an ASC’s ownership is watching the facility is to look at the minutes. If the minutes lack important details, surveyors will notice.
“The administrator needs to make sure the governing body gets together, and that proper minutes of the meetings are written down,” Goehle says.
One problem area Goehle often sees involves documentation of quality improvement processes.
“We’ve seen places that might or might not have a great quality improvement program that are not reporting the results to their governing body,” he explains.
Anytime an ASC conducts a QI project, this must be documented and shared with the governing board. The board’s minutes should reflect that information, and the minutes should show whether the board approved the changes that occurred because of the QI process.
“Maybe the ASC has to make changes in its fall prevention program,” Goehle says. “They need to report it to governing body because they’re responsible.”
“I do not necessarily believe the governing body needs to approve of changes that are appropriate and consistent with providing higher quality healthcare,” Steven A. Gunderson, DO, medical director and CEO of the Rockford (IL) Ambulatory Surgery Center, offers. “However, I do think that the changes should be brought to a governing body meeting and presented to the board. It does not take board permission for the nursing staff to implement changes that improve patient care.”
• Stay current with credentialing. “There are a couple of different areas where ASCs can get into trouble,” Goehle says. “One, is they need to remember to credential all physicians, allied health professionals, and residents.”
Sometimes, administrators forget that residents’ credentials must be checked before they can see patients in an ASC, he notes.
“Check with the institution where the resident is being educated,” he says. “Double-check the resident’s medical license, and go to a primary source, such as a school.”
Also, make sure the governing body approves, Goehle adds.
“Have a credentialing chart for every doctor who works in your facility,” he suggests. “They are granted privileges for a period of time, and then you need to make sure those doctors re-credential themselves.”
ASC directors sometimes forget to check credentials after the first time, or there might be lag time between when one credential expires and another one begins, he says.
For nurses who are ASC employees, credentialing is conducted through their employment process.
• Address infection control and sterilization. “This is the hottest topic right now,” Goehle says. “There can be a lot of different issues, including not handling drugs properly.”
For instance, when handling multidose drugs, the ASC’s staff should make sure drug labels read multidose. These drugs must be drawn outside of patient care areas.
“Say you’re drawing up lidocaine for a patient,” Goehle explains. “This has to be drawn up into the syringe, outside of the patient area.”
Drawing multidose drugs near a patient can create a risk of cross-contamination, he adds.
“These are logical things, but if something is labeled single-use, you can’t give it to multiple patients,” he says. “Or sometimes someone will not label syringes after they draw them up.”
Surveyors are cautious about observing a facility’s cleaning processes, to make sure it’s conducted properly.
“This past week, we walked into a place where they were doing what they thought was sterilization,” Goehle says. “But they were taking the pan out of the operating room and dropping it into the ultrasound cleaner without disinfecting it ahead of time.”
The staff did not know they were supposed to wash it first with disinfectants.
“I walked into the room and saw the sink with all the disinfectants in it, and the sink was clean,” he says. Another place was washing tools with fluids that were not certified as disinfectants. “We said, ‘You have to make sure that any fluid you are using for cleaning is known by the infection control nurse, and the nurse has to sign off on them,’” Goehle says.
As a best practice strategy, ASC staff should read the manufacturer’s instructions for cleaning fluids and all instruments and equipment they’re using.
“Surveyors will come in and observe and ask, ‘What are the instructions for this?’” Goehle explains. “You will want to pull out the instructions right away to show what you’re doing.”
• Follow up with training. Training is something many ASCs want. Goehle says he’s often asked the following questions:
- How do we train staff?
- How do we retrain them?
- How do we train new people?
ASCs sometimes experience high turnover, and administrators say they don’t have time to train new staff, Goehle says. But this is one area where management cannot cut back.
“You don’t have time to fix the problems that occur because you didn’t train them in the first place,” he says.
Training programs should include as-needed inservices and mandatory, annual training sessions. The mandatory sessions should cover the things that must be part of staff’s annual training.
“I’m finding that organizations are getting confused about what’s mandatory and what’s an inservice,” Goehle says. “They forget the mandatory training has to be done every year.”
Inservices should be held to cover processes whenever the organization sees that something is not performed correctly.
The smarter ASCs create policies and procedures, train staff on how to follow them, and ask experts to review both written policies and the actions employees take to follow the organization’s policies.
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