The key to successfully launching quality improvement projects is to study the big picture by asking employees which problems to tackle first.

• Another important step is to get physicians on board with the QAPI process.

• Form a quality improvement team and educate staff with visual aids.

• Look for variations in practice, singling out small QAPI steps that can be taken first.

Surgery center administrators might find that initiating a quality improvement process is daunting and time-consuming. However, the process can reveal much about the ASC, its staff, and its operations. The key is to examine the big picture, including asking employees which problems should be the first ones tackled under a QAPI program, says Carolanne Reho, MHA, BSN, RN, CNOR, senior director of clinical services at AmSurg.

“I often tell surgery centers to rely on the expertise and experience of their staff to help them choose a topic,” Reho says. “There’s a lot of cumulative experience in people who work at surgery centers.”

ASC directors should reach out to their employees, asking them about challenges they face and engaging them in the QAPI process, she adds.

“Get people to talk about their jobs on a very basic level,” Reho suggests. “Ask them if there are things that inhibit them from doing their jobs well. Are there things that make them more efficient at their jobs?”

Engaging staff to use their expertise to identify areas for improvement is an important part of the process, she adds.

The following are some additional suggestions and strategies for starting a QAPI program:

• Bring physicians on board. “First and foremost, you need physician support,” says Yvonne Visbeen, BSN, RN, senior clinical director at AmSurg. “Some centers have a lot of physician involvement, and this leads to a thriving program. When physicians are not involved, it can be hard because directors have to drive the process by themselves.”

There are ways to obtain physician buy-in. “Doctors are very data-driven, and they’re competitive,” Visbeen notes. ASCs can engage physicians in the QAPI process if administrators can present physicians with data about any quality improvement topic, whether it’s patient satisfaction or what one supply costs vs. another, she adds. For physicians who own a portion of the ASC, this works especially well, Visbeen offers.

“You can say, ‘We’d like to do a study to see if we like this supply from this manufacturer as well as the one we use, but we’ll save $5 per item,’ and the physicians will be on board,” Visbeen says.

• Form a quality improvement team. An ASC’s quality improvement team should include staff from all areas, Visbeen says.

“Everyone has their own world they work in, but if you have a QI team, it could bring people together,” she says. “You’re hopefully building connections between this team and how it might affect someone else down the road.”

ASC directors might look for employees with skills that would help a quality improvement team. For instance, there might be a staff member who is skilled at creating Excel spreadsheets and graphs, which could be used in data analyses.

“You want to tap people where their interests are, and that means you must know your staff,” Visbeen suggests. “Hold meetings and say, ‘I’m thinking of doing some quality improvement in this area, and I need some help.’ Start with small things, something that staff can take ownership in.”

Initial projects might affect employees’ daily workflow, and the ASC director can look for volunteers who are willing to study the issue and find solutions.

• Educate with visuals. ASCs might post visual representations of QAPI initiatives throughout the center. For instance, posters could list patient satisfaction survey results.

“If everyone congregates in the lunch room, put posters in a place people are walking by,” Visbeen suggests. “If I walk into a center and ask any employee what the surgery center is doing with quality improvement, the employee should be able to tell me. But 90% of employees cannot identify a quality improvement project because, one, we’re not including them in QI, and, two, we’re not giving them any visual cues.”

Hanging posters and other visuals in the surgery center will educate staff about QAPI in a way that expands its reach. “Even if they’re not involved in QAPI, they are aware of it because they see it on the bulletin board,” Visbeen adds.

• Identify variations in practice. “This is something any surgery center can do,” Reho says. “If it’s a big topic, you could focus on smaller aspects of it.”

For instance, the surgery center might tackle the big topic of patient safety and quality in anesthesia care, breaking it down into the smaller issue of post-op nausea and vomiting.

“An ASC might have three different anesthesia providers managing these patients,” Reho says. “You can use peer review in this process, tracking these specific providers’ patients and their rate of post-op nausea and vomiting.”

The ASC then tracks nausea and vomiting cases over a two-month period and compares patient rates of this problem across the three physicians.

“See if there’s a trend,” Reho suggests. “Maybe one doctor [treats] a majority of the patients with post-op nausea and vomiting.”

When surgery center administrators track a trend by provider and procedure, they are focusing on the problem and its possible cause. Administrators can study these data even more by examining:

- What agents are used?

- What type of procedure have the patients undergone?

“You’ve started with the big, general topic and then focused on that until you get more specific items to track,” Reho says. “Once we track and trend specific items, we can look at ways to effect change.”

A potential finding might be that one specific inhalation agent resulted in a greater proportion of patients with post-op nausea and vomiting. The ASC director discusses this finding with the quality improvement team, and the team proposes a solution to implement and monitor.

• Build on small successes. “You can use data to present to physicians and to champion quality improvement every day,” Visbeen says. “Get away from thinking it needs to be a long and involved study; look at something that is a daily problem.”

For example, a small QAPI project might focus on discharge instructions. Visbeen recalls one discharge instruction quality improvement initiative. Patients said in a survey they didn’t feel that certain discharge items were adequately addressed.

“So, we gave surgery centers instructions on what the discharge instructions should say, and we suggested they ask staff, ‘How can we help patients understand discharge instructions before they leave the facility?’” Visbeen recalls.

Some centers solved the problem with laminated discharge instructions. Staff handed these instructions to patients pre-procedure. This gave patients time to ask questions prior to the procedure.

“Start discharge teaching before [patients] walk in the door,” Visbeen says. “That’s been valuable in improving patient satisfaction.”

An additional solution is to place a poster in the consultation area where patients wait to speak with physicians. “It’s a visual cue for them and family members,” she says. “The poster lists the things patients should be aware of [and] the reasons they should call their doctor.”

• Network with other surgery centers. ASC directors might attend state meetings or conferences and ask their peers how they addressed QAPI needs.

“Networking at a local level is extremely helpful,” Reho says. “For our corporation, we can facilitate networking and link up people.”

Solo ASCs must be resourceful. Attending meetings and events with other ASC leaders is a good place to start. An ASC director can collect email addresses and phone numbers from other ASC directors and then contact them when an issue or question arises.

“Reach out to people who are doing the same job you’re doing,” Reho says.

The Ambulatory Surgery Center Association (ASCA) is another resource for networking and peer information.

“ASCA has a daily blog, sent by email,” Reho says. “People ask questions about their processes and whether anyone else deals with these same issues.”