Building a Quality Reporting Program for Ambulatory Surgical Centers

1. Building a Quality Reporting Program for Ambulatory Surgical Centers

2. About the QIN-QIO Program Leading rapid, large-scale change in health quality: • Goals are bolder. • The patient is at the center. • All improvers are welcome. • Everyone teaches and learns. • Greater value is fostered.

3. 11th Statement of Work (SOW) QIN-QIO Map

4. TMF QIN-QIO • The TMF QIN-QIO serves the region of Arkansas, Missouri, Oklahoma, Puerto Rico and Texas. • TMF has subcontracted with strong, experienced quality improvement partners to provide expert technical assistance and quality improvement support for participating providers across the region. • Arkansas Foundation for Medical Care • Primaris (Missouri) • QIPRO and Ponce Medical School Foundation (Puerto Rico) • TMF Health Quality Institute (Texas and Oklahoma)

5. Join the TMF QIN-QIO Websitehttp://www.TMFQIN.org • Provides targeted technical assistance and will engage providers and stakeholders in improvement initiatives through numerous Learning and Action Networks (LANs). • The networks serve as information hubs to monitor data, engage relevant organizations, facilitate learning and sharing of best practices, reduce disparities and elevate the voice of the patient.

6. HSAG: Your Partner in Healthcare Quality • HSAG is the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands. • Committed to improving healthcare quality for more than 35 years • QIN-QIOs in every state/territory are united in a network under the Centers for Medicare & Medicaid Services (CMS). • The Medicare QIO Program is the largest federal program dedicated to improving healthcare quality at the community level.

7. HSAG’s QIN-QIO Territory Nearly 25 percent of the nation’s Medicare beneficiaries HSAG is the Medicare QIN-QIO for Florida, California, Ohio, Arizona, and the U.S. Virgin Islands.

8. ASC Quality Report QIN-QIO Results: HSAG and TMF ASC Quality Report QIN-QIO Results

9. ASC-4

10. ASC-5

11. ASC-8

12. ASC-9

13. ASC-10

14. Go for It: Create a Quality Improvement Project Using ASCQR Measure Data Mary Ellen Wiegand, RN, LHRM, CASC, CNOR Quality Improvement Specialist Health Services Advisory Group (HSAG) Ambulatory Surgical Center Quality Reporting = ASCQR

15. Objectives • Describe the link between quality reporting and quality improvement • List the steps for creating a quality improvement study • Use your facility’s ASCQR data to create a quality improvement study

16. Linking Quality Reporting and Quality Improvement • The ASCQR Program requires Ambulatory Surgical Centers (ASCs) to gather and report specific measure data to be eligible for annual payment updates. • Data are essential to Quality Improvement • Identify and describe system and process problems • Establish baselines and goals • Compare your performance to other units/facilities • Track changes/trends over time • Garner support for quality improvement initiatives

17. You Submitted the Data—Now What? • ASCQR measure data has been collected and reported AND • Certification and accreditation agencies require quality improvement studies as part of their quality programs. You have the data…use it!

18. Initial Steps • You have just taken the first steps in developing a quality improvement study! • Begin to organize and document your actions. • Be consistent with requirements for certification and accreditation. • AAAHC* 10 Elements • CMS QAPI** • Joint Commission *Accreditation Association for Ambulatory Health Care**Centers for Medicare & Medicaid Services Quality Assessment and Performance Improvement

19. What to Study? • Look at the data you have submitted for the ASCQR program. • Reports have been provided by HSAG and TMF • You may want to start with: • ASC-8, Influenza Coverage among Healthcare Personnel OR • ASC-9 &10, Colonoscopy measures

20. Step 2: Establish Your Goal • Compare your facility to your state and the nation. • Use this as a benchmark to establish your facility’s goal(s). • Create a goal statement that is SMART. • S.M.A.R.T. = • Specific • Measureable • Attainable • Relevant • Time-bound

21. Step 3: Describe Your Data • Describe the data being used in your study. • Data as specified by the reporting requirements • Describe the numerator and denominator categories • Use the current Specifications Manual located on Quality Net: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228772475754

22. Tools for Collecting Data • Describe how data are collected, by whom, and what tools are used. Examples • ASC-8 • Data collection form available on the NHSN website: http://www.cdc.gov/nhsn/ambulatory-surgery/vaccination/index.html • ASC-9 & 10 • Pocket cards • ASC-9 & 10 collection tool: https://www.hsag.com/en/medicare-providers/quality-reporting/facility/ambulatory-surgery-centers-asc/asc-9--asc-10--a-study-to-promote-appropriate-use-tutorial/

23. NHSN Data Collection Form

24. ASC-9 & ASC-10 Endoscopy Collection Tool

25. Collection/Documentation Cards Endoscopy

26. Step 4: Analyze Your Data • Review your previous reporting periods. • Describe the findings. • Where are your best opportunities for improvement? • Presenting data graphically may be visually helpful. • Your QIN-QIOs can provide assistance with this. • After review of the data, you should have a good reference point of where to begin.

27. Step 5: Design and Implement Interventions

28. Examples of Solutions and Strategies: ASC-8 • In-service education • Provide vaccine at no cost • Workplace immunization policies. • Post information https://www.hsag.com/QIFluData/.

29. Examples of Solutions and Strategies: ASC-9 & ASC-10 • Develop standardized documentation templates for the doctors to follow. • Engage the medical director as your project champion. • Supply source documentation, if necessary. (Specifications Manual) • Random chart reviews • Focus on different practitioners. • Frequency: daily, weekly, monthly; Have your committee decide.

30. Step 6: Re-measure, Re-analyze the Data

31. Step 7: Share Your Results • Report your findings to: • Staff • Leadership • Facility’s governing body • Reinforce the need for continued quality improvement efforts.

32. Discussion • Are there any projects you are working on? • Please share! • Need help getting started?

33. Resources 33

34. Resource Links • QualityNet: https://www.qualitynet.org • Quality Reporting Center: http://www.qualityreportingcenter.com • CMS.gov: State Operations Manual Appendix L - Guidance for Surveyors: Ambulatory Surgical Centers https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf

35. Tutorials • Include WebEx recording and tools • ASC–9 & ASC–10: A Study to Promote Appropriate Use https://www.hsag.com/en/medicare-providers/quality-reporting/facility/ambulatory-surgery-centers-asc/asc-9--asc-10--a-study-to-promote-appropriate-use-tutorial/ • Take a Shot: Create a Quality Improvement Project Using ASC-8 Data https://www.hsag.com/en/medicare-providers/quality-reporting/facility/ambulatory-surgery-centers-asc/how-to-create-a-quality-improvement-project-plan-tutorial-and-presentation/

36. Conclusion and Reminders • These steps are a basic approach to any quality improvement programs/projects. • Though your study may be complete, continue to report to Quality Net and NHSN • Your QIN-QIOs are here to help you get the most from your data!

37. Thank you! Mary Ellen Wiegand, RN, LHRM, CASC, CNOR HSAG Quality Improvement Specialist 813.865.3446 |mwiegand@hsag.com

38. TMF QIN-QIO Suzie Buhr, RN, BSN, CPHQ, CMQP Quality Improvement Consultant TMF Quality Innovation Network Suzie.Buhr@area-b.hcqis.org 214-477-1407 www.TMFQIN.org

39. Thoughts? We would greatly appreciate your feedback on today’s presentation. Please take a minute to answer the questions that will appear on the right side of the screen after the presentation. Thank you. This material was prepared by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, and Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-QINQIO-D1-17-28