Data That Matters: Are You Taking Advantage of the ASC QC?

From benchmarking reports to helpful tools and resources, here’s help.

Tracking down all the quality measures necessary to run a safe, efficient surgery center can feel like an impossible task for busy ASC leaders. That’s where the ASC Quality Collaboration (ASC QC) comes in.

Expertise from multiple perspectives

Founded in 2006, the ASC QC brought together ASC industry and professional associations, ASC management companies, accreditation organizations, state ASC associations and healthcare IT companies with one shared purpose: To develop, support and promote standardized measures of quality appropriate to ASCs. To this day, the ASC QC is the only organization solely dedicated to advancing patient safety and quality care at ASCs.

One driver for the creation of the ASC QC was the belief that quality measures should be within the control of the surgery center — and understandable and accessible to its key stakeholders. Initial development efforts focused on aspects of care that all ASCs could report on regardless of specialty, but we’ve since significantly broadened our focus. Current development activities take other considerations into account, including gaps in measures identified by national policy-setting organizations. Our organization serves as a resource center for ASCs on a wide array of patient safety, quality-of-care and service-excellence issues. Here are several ways in which we help ASCs.

Quarterly quality benchmarking reports

Once quality measures were established by the ASC QC (See sidebar, next page), members voluntarily submitted data to the organization on a quarterly basis. This data appears in quarterly benchmarking reports on the ASC Quality Collaboration website at osmag.net/qreport. Any ASC can access the data, which includes all measures on the accompanying list except those pertaining to surgical hair removal and timing the administration of IV antibiotics. Data is collected from 14 ASC QC member organizations and represents more than two million patient admissions at 2,000 ASCs.

Collaboration with regulatory bodies

The ASC QC regularly meets and communicates with regulatory agencies and other prominent industry organizations, which has led to longstanding working relationships that allow the ASC QC to gain early knowledge of and provide input about proposed new measures that are in development.

Our organization then offers centers the opportunity to participate in pilot testing of new measures. Early use of the measures has proven beneficial for those centers who participated as early adopters, and the lessons learned from these early-adopter ASCs are shared across the ASC QC.

The ASC QC also conducts an annual in-depth analysis of the CMS Proposed Rule and submits comments regarding the quality reporting components of it. Once the Rule is finalized, the organization helps ASCs implement the changes. Regulatory agencies share insights and updates about their ASC-related activities at the organization’s annual ASC Quality Conference for its members.

Educational toolkits

Fostering improvement requires measurement, which is why we offer ASCs the opportunity to benchmark against the publicly reported measures. When ASCs track and compare the results of the various measures, opportunities for improving quality and safety processes are identified. Use of the ASC QC benchmarking data also fulfills accreditation requirements for external benchmarking.

We also offer eight educational ASC QC toolkits on our website, each specifically designed to help ASCs improve their performance. These toolkits are accessible to all ASCs and provide assessment tools, implementation aids, training materials, monitoring tools, workplace reminders and guidelines from leading authorities. They are also full of workplace posters, training videos and sample policy-and-procedure templates. The toolkits cover hand hygiene, safe injection practices, point-of-care devices, environmental infection prevention, single-use reprocessing, endoscope reprocessing, prevention of patient falls and sterilization and high-level disinfection. In addition, a new toolkit is forthcoming on wrong-site, side, patient, procedure, implant events.

Growth and awareness initiatives

To bolster awareness and ensure more centers are exposed to our many offerings, the ASC QC is booking speaking engagements, writing journal articles and interacting with state ASC organizations. We’re also recruiting new members. If you’re interested in learning more about the ASC QC, please reach out to us via our email addresses below.

We’re also working to enhance our social media presence and redesigning our website to make it more user-friendly. Of course, our primary focus will always remain on providing ASC leaders with data and information that will advance patient safety and quality care. Our recent work on a new measure is a prime example. With the transition of more complex procedures from inpatient to outpatient, the ASC QC is working with the CDC to develop a new measure related to total joint replacements.

Positioned to deliver results

ASCs have a long history of tireless commitment to safe, quality care. The continual migration of complex procedures from inpatient facilities to ASCs results in considerable cost savings for payors and patients; however, value is not achieved without demonstrating safety and quality. Through our longstanding relationships with regulatory agencies, our quarterly benchmarking and our best-practice toolkits, the ASC QC is in a unique position to support these efforts. OSM

FOCUS AREAS

11 Measures for ASC Health

The ASC Quality Collaboration has developed the following 11 measures for performance improvement and quality reporting purposes:

• All-Cause Emergency Department Visit Within One Day of Discharge
• All-Cause Hospital Transfer/Admission
• All-Cause Unplanned Hospital Admission Within One Day of Discharge
• Normothermia Outcome
• Patient Burn
• Patient Fall in the ASC
• Unplanned Anterior Vitrectomy
• Wrong-Site, Wrong-Side, Wrong-Patient, Wrong-Procedure, Wrong-Implant
• Toxic Anterior Segment Syndrome (TASS) Outcome
• Appropriate Surgical Hair Removal
• Prophylactic IV Antibiotic Timing

The first eight measures on the above list are currently included in the CMS ASC Quality Reporting Program, which began in 2012.
—Kathy Wilson, RN, MHA, and Becky Ziegler-Otis, MHA, CASC