EXECUTIVE SUMMARY

Quality assurance and performance improvement (QAPI) projects are a way to work toward every surgery center’s goal of providing safe, cost-effective, high-quality care.

• Surveyors typically ask to see a site’s QAPI plan.

• QAPI is a continual process of studying data and analyzing the information.

• It’s about acting proactively to prevent problems.


Before delving into quality assurance and performance improvement (QAPI) projects, some people might view them as mysterious, enigmatic puzzles. But they’re not. The quality improvement process can be straightforward and simple. One way to envision QAPI is to see it as a process for ambulatory surgery center (ASC) leaders to continually strive for improvements in surgery center operations.

“One of my goals in working with centers is to get them to see that quality improvement is a culture,” says Yvonne Visbeen, BSN, RN, senior clinical director at AmSurg in Nashville, TN. “We’re trying to improve everything we do with the goal of providing really safe, high-quality care in a cost-effective way.”

Accreditation organizations and other surveyors are interested in ASCs’ quality improvement projects because this shows that the site takes patient safety and quality care seriously. One of the first items surveyors ask to see is a site’s QAPI plan, says Jan Allison, RN, CHSP, senior director of regulatory at AmSurg and a national speaker about QAPI.

Surgery center leaders should look at the big picture as they tackle QAPI projects, suggests Carolanne Reho, MHA, BSN, RN, CNOR, senior director of clinical services at AmSurg. Reho sometimes speaks at national surgery center conferences about QAPI and quality improvement.

As a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC), Reho often is asked what should be the center’s focus of study.

“Choosing a topic is very challenging for people because they’re so used to problem-solving on a daily basis that they don’t see the things they are dealing with or know how to track and trend events,” Reho explains. “A lot of times there are things they do a lot or see a lot, and these are right there in front of them, but it’s hard for them to focus on these things because they see them every day.”

According to Allison, a successful QAPI plan will include procedures for data collection, identifying problems, and creating steps for improvement with follow-up. Two important questions:

• Are we meeting the standard of care?

• Are we always looking to improve?

“I’d look at how robust it is, whether it’s compliant with expectations, compare it to the requirements, and look at indicators and what is being monitored,” Allison says. “Having a robust QAPI program is something everybody needs to do; it’s what drives patient safety.”

Surgery centers with QAPI programs will examine data to see which processes need improvement to keep patients safe and to prevent harm. “That’s the whole purpose,” Allison adds.

QAPI is a continual process of studying data, analyzing what the information shows, making changes based on this information, and then monitoring to make sure improvements are sustained, Visbeen says. Quality improvement teams should include staff from every area of the center, Visbeen adds. (See story in this issue on how to establish QAPI projects.)

“Sometimes, a facility has a feeling of where a problem is, but it’s not something they’re measuring,” Allison says. “They can collect data on those areas to see if there’s an opportunity for improvement.”

For example, a surgery center might have a great record when it comes to wrong-site surgeries; internal data might show zero mistakes in this area. But this doesn’t mean that the center should not bother to create a QAPI plan for this issue.

“Maybe, the surgery center realizes they don’t perform a time-out process well,” Allison says. “And they open up the risk of having a wrong-site mistake when they don’t do it well, so they realize they need to improve their time-out process.”

A QAPI plan can be implemented proactively. Administrators don’t have to implement a plan that is reactive to data that identify problems, Allison adds.

“That’s what performance improvement is — you’re proactive in preventing the problem from occurring,” Allison says.

Finding areas to improve should not be an issue for any healthcare organization.

“There are so many different and great areas that people can look at,” Reho says. “In my experience, centers that have embraced QAPI are very successful and see the benefit of looking at appropriate topics for themselves, and when they see an improvement take place, it’s so rewarding and so important.”

When ASCs first tackle QAPI projects, one step is to talk with staff.

“Ask them what quality means to them,” Allison suggests. “Sometimes, people don’t understand; they can grumble about things going on, but not necessarily understand that by addressing it, there could be an opportunity to improve it.”

Employees will know which processes and areas are problematic. They might help leaders generate ideas for projects. A surgery center’s nurses play a large role in quality improvement because of their hands-on patient care, Allison notes.

“QAPI is monitoring to see if we’re doing what we’re supposed to do,” she adds. “Are we doing best practices? Do we have an opportunity to improve? And, what is our data telling us?”