An infection control and prevention quality improvement project should be based on a set of standards. These standards start with federal, state, and local regulations, as well as industry standards, such as those from AORN, CDC, SHEA, and the Association for Professionals in Infection Control and Epidemiology.

Quality assessment and performance improvement (QAPI) is a process that should be a part of the policies of every ASC, according to Elethia Dean, RN, BSN, MBA, PhD. Regulatory agencies require that the policies are focused on high-risk, high-volume issues and problem-prone areas.

“Secondly, every QAPI program must consider incidences, prevalence, and severity of problems that may arise in the ASC,” Dean says. “The ASC should also look at things that affect health outcomes, patient safety, and quality of care.”

According to Dean, QAPI programs also should be data-driven and answer these and additional questions:

• What are the procedures the ASC performs most often?

• Looking at data from all recent surgeries, what are the problem areas?

• What is the rate of hospital admissions post-surgery?

• What is the rate of complications post-surgery?

• What procedures carry the highest risk?

• Which populations of patients pose the highest risk?

• What is the rate of post-op infections?

• Are there any patient attributes that could lead to problems, such as patients who are unsteady in their gait?

“Those things indicate the quality of care you give in the ASC,” Dean says. “Do internal benchmarking and compare against past performance, as well as external benchmarking, and benchmark against all like entities.”

Ensuring quality in an ASC is key to the success of the ASC. Facilities that provide high-quality care tend to treat a higher volume of patients, leading to better success financially, as well as with patient outcomes. Therefore, it is imperative that each ASC keep a finger on the pulse of what could affect quality of care and infection prevention.