QAPI: The Future of Reporting Quality Care to the Different Agencies that Govern Our Practice

1. QAPI: The Future of Reporting Quality Care to the Different Agencies that Govern Our Practice Beverly Kirchner, RN, BSN, CNOR, CASC September 2010

2. Objectives • Discuss the new standards on quality reporting for CMS in a surgery center • Discuss the ASC Quality Collaboration work completed and approved by NQF for surgery centers. • Describe a QAPI plan that meets the accrediting bodies requirements. • Describe the future of quality care and reporting.

3. Brief Overview of Agencies that Govern ASC’s • CMS • State • OSHA • CDC • NFPA • NQF • Accrediting Organizations

4. 416.41 Governing Body and Management • Must have Governing Body • Assumes full legal responsibility for operation of center • Oversight & accountability • Quality Assessment • Performance Improvement • Ensures polices & programs are followed • Ensures the center provides quality care in a safe environment

5. 416.41 Governing Body and Management Continued • Oversees contracted services • Transfer agreement • Written • Hospital CMS Certified • Assures all physicians & allied health staff have: • Education • Privileges • Peer Review • Utilization review • Assures physicians have admitting privileges at a hospital that is CMS certified

6. 416.41 Governing Body and Management Continued • Disaster Plan • Addresses care for patient & staff • Addresses any event that could threaten the health and safety of anyone in the center • Coordinates plan with state & local authorities • Conducts drills at least annually

7. Governance Organizational Chart BOARD Medical Executive Committee Administrator Director of Nurses Business Office Manager

8. Committee Organizational Chart BOARD MEC Administrator QAPI Committee Safety Officer Nursing Care Committee Radiation Safety Infection Control Pharmacy Employee Health

9. 416.42 Quality Assessment & Performance Improvement • Develop • Implement • Maintain ongoing program • Data driven • Demonstrates measurable improvement

10. 416.42 Quality Assessment & Performance Improvement Continued • Center Must • Measure • Analyze • Track quality indicators • Adverse patient events • Infection Control • Data must be used to monitor effectiveness & safety of services provided • Identify opportunities for improvement • Focus on high risk, high volume, problem-prone areas • Number of scope projects conducted annually must reflect complexity of ASC’s services

11. 416.42 Quality Assessment & Performance Improvement Continued • Documentation • Reason • Description • Specifies data collection method, frequency & details • Center must allow sufficient staff • Time • Information Systems • Training & education

12. ASC Quality Collaboration • ASC Quality Collaboration • Formed in 2006 • Focus: on healthcare quality & safety • Today’s Focus • Measure development • Public Reporting of Quality Data • Advancing ASC Quality • Advocacy

13. National Quality Forum Endorsed Measures • Patient Fall • Patient Burn • Hospital Transfer/Admission • Wrong Site, Side, Patient Procedure, Implant • Prophyloctic IV Antibiotic Timing • Appropriate Surgical Site Hair Removal

14. The ASC Quality Collaboration is dedicated to advancing high quality, patient-centered care in ambulatory surgery centers.

15. How are we doing? • Rate of patient fall in the ASC 0.149 per 1000 admission • Represents the experience of 1,278,879 ASC admissions seen 1,130 facilities between January 1 and March 31, 2010

16. Rate of Patient Burns: 0.037 per 1000 Admission • Represents the experience of 1,275,578, ASC admissions seen in 1,123 facilities between January 1 and March 31, 2010.

17. Rate of Hospital/Admissions: 1.081 per 1000 admissions • Represents the experience of 1,334,614 ASC admissions seen in 1,185 facilities between January 1 and March 31, 2010.

18. Wrong Site, Side, Patient, Implant events: 0.034 per 1000 admissions • Represents the experience of 1,308,530 ASC admissions seen in 1,169 facilities between January 1 and March 31, 2010.

19. Percentage of ASC admissions with Antibiotics ordered who received antibiotics on time: 95% • Represents the experience of 692,129 ASC admissions seen in 674 facilities between January 1 and March 31, 2010.

20. ASC Tools for Infection Prevention • Hand Hygiene • Safe Injection Practice • Point of Care Devices Future Tool Kit • Environment of Care Website: ASC Quality.org Last accessed: August 23,2010

21. Elements of an ASC QAPI Plan • Mission Statement components: • Direct activities concerning design of new services • Monitor processes • Assess processes • Measure quality of care • Patient satisfaction • Peer review • Service • Patient outcomes • Look for opportunities to improve

22. Elements of an ASC QAPI Plan • Program Plan components: • Discuss ongoing process • Discuss responsibility of Board • Discuss responsibility of Committee • Discuss reporting system in the facility • Purpose: To provide service excellence, and the improvement of patient outcomes and processes by acting on opportunities for increment performance improvement.

23. Elements of an ASC QAPI Plan • Leadership Responsibilities: • Set expectations • Manage processes • Set priorities to measure • Improve the quality of: • Governance /Education • Management/ Education • Clinical care/ Education • Patient care • Support activities • Safety • Risk management • Infection prevention

24. Elements of an ASC QAPI Plan • Design of approach to improving process • Design of processes • Provide resources • Implementation of performance processes • Follow-up on performance processes • Assess if there is improvement • How effective is the improvement

25. Quality Assessment: Performance Improvement Committee • Members include: • Chair • Anesthesia provider • Surgeon • Center administrator or clinical coordinator • Staff members • OR • Admission • PACU • Infection Preventionist • Safety Officer • Risk Manager • Business office

26. Quality Assessment Performance Improvement Committee Responsibilities: • Review • Process deficiencies • Problems • Failures • User error • Select and prioritize improvement opportunities • Identify resource needed for a project • Request resources from the Governing Board through Leadership team • Create PI project design • Complete an assessment of potential problem • Research issue • Develop goals • Design tool for data collection

27. Quality Assessment Performance Improvement Committee Responsibilities Continued: • Determine expected outcome to measure • Implement change • Obtain Governing Board approval • Educate staff • Reporting results

28. The Chair of the Quality Assessment Improvement Committee is responsible for providing program support to the staff and leadership.

29. Quality Assessment Performance Improvement Committee’s work and reports are ongoing. • Establish a calendar for meetings • Establish a schedule/agenda on what is reported at each meeting • Prepare a quarterly report of all activities to be presented to the Medical Executive Committee and Governing Board • QAPI documents are kept confidential

30. Example of QAPI Meeting Calendar

31. QAPI Committee Reports Organization Wide to • Annual Medical Staff Meeting • Quarterly Medical Executive Committee • Quarterly to the Governing Board • Monthly at Staff Meeting

32. QAPI Committee Reports outside of Committee meeting do not include the • Names of patient, provider, or employee • Only QAPI Committee Members are given identifying information. Only committee members can attend meeting.

33. Successful QAPI Programs • Encourage staff participation & support program • Encourage medical staff participation & support program • Provide easy ways to make suggestions or communicate process problems identified • Medical Executive Committee and Governing Board support the program • Leadership supports the program

34. Developing a Performance Improvement Program/Project • Resources • Budget dollars for resources needed • Obtain approval Governing Board • Program • Program/Project selection should be important to the organization • Doing the right thing • Doing the right thing well • Patient & Organization Focused • Patient or organizational rights • Patient assessment • Patient rights • Educational • Continuity of care • Improving organization performance

35. Developing a Performance Improvement Program/Project Continued • Improve Leadership • Manage Environment • Manage Human Resources • Manage Information • Prevention • Safety

36. Program Should Reflect • Organizational Mission and Vision • Be collaborative with different services • Support for organization • Meet the needs of the organization

37. Program/ Project Should Identify • Dimensions of performance that will be most affected • Improved performance goal or goals • How the team will determine if new process is performing the way the team anticipated • Who will work on the program/project

38. Program/Project Data Collection & Performance • Focus on process or outcome • Provide base data • Identify opportunity for improvement • Create process redesign • Collect data –ongoing • Re-evaluate –make changes if needed

39. Program/Project Assessment • Compare past performance with standards, policy, Best Practices • Monitoring is ongoing • Focus intense assessment on: • Major discrepancies between pre & post-op • Confirm medication, transfusions or any other unexpected reactions • Review all medication errors • Any unexpected event or outcome

40. Quality Assessment Performance Improvement Committee will oversee the review and revision of the center’s policies and procedures annually.

42. Monitoring Unplanned Hypothermia Events Quality Assurance Project

43. Purpose: To develop a standardized process in which unplanned hypothermic events occur in less than five (5) percent of patients undergoing an invasive procedure in the center.

44. Background/Significance • It is estimated that 50% to 90% of patients undergoing a surgical procedure will experience a hypothermic event. • An unplanned hypothermic event is preventable. • Hypothermia is defined as a core temperature below 36°C (96.8 °F) • Vasoconstriction occurs during a hypothermic event • Vasoconstriction: -Reduces flow of nutrients to the body -Decreases oxygen delivery -Inadvently alters wound healing - neurophils / (white blood cells) can't function at optimum levels

45. Perioperative challenges that effect normothermia in a patient: - low ambient room temperatures - patients admission anxiety level - irrigation fluid - IV fluid - Size of skin exposure to room temperature - Prep solutions - Length of surgery - Blood and fluid loss - Anesthesia/anesthesia gases • Patients at risk for unplanned hypothermic event include: - neonates -older adults

46. -females -fluid shifts in patient -peripheral vascular disease -cardiovascular disease -endocrine disorders -open wounds -Renal disease • Unplanned hypothermic events affect body systems -Respiratory -Cardiovascular -Adrenergic and immune systems -Alter medication metabolism -Variations in electrolyte levels

47. General and regional anesthesia affect core body temperature • Affected ways to decrease risk of an unplanned hypothermia event: -maintain admission temperature -adequate pain control -hydration -increase ambient room temperature -provide warm blankets -provide warm IV fluid -provide warm Irrigation fluid -humidified and warm anesthesia gases -forced air warming

48. Tracking Design: Typical Descriptive Study Phenomenon of Interest Measurement Descriptive Interpretation Hypothesis Prevention of Unplanned Hypothermia Event Audit Tool Interactive Care Plan & Clinical Pathway 95% Compliance

49. Method: PDCA Method -Problem: Interventions for unplanned hypothermia are not followed on every patient. -Opportunity: Improve communication (verbal & written) between pre-admission nurse and admission nurseImprove patient satisfaction by - Review organizational interventions -Educate staff the affects of hypothermia on the patients outcome • -Review on organizational policy

50. Patient Flow for Prevention of Unplanned Hypothermia • Preadmission Nurse plan to patient’s meddevelops patient care plan and attaches ical records. Patient is scheduled For Surgery Admission nurse performs patient care hand off to operating room circulator. OR Circulator communicates to OR Team during 1st time out the risk the patient has for unplanned hypothermia event and interventions started based on clinical Pathway and Care Plan. Preadmission nurse completes pre-admission nursing assessment. Admission nurse further assesses patient by taking vital signs and initiates interventions for preventing unplanned hypothermia based on risk analysis. Preadmission Nurse develops patient care plan and attaches plan to patient’s medical records. OR Circulator and anesthesia provider performs patient care hand-off with PACU Nurse. PACU Nurse measures temperature. If patient is hypothermic surgeon and anesthesia provider are notified. Discharge nurse re-enforces post-op education to patient and patient's care giver. Patient care hand-off is performed between discharge nurse and care giver. OR Circulator adds protocols and interventions the surgeon and or anesthesia provider request. PACU nurse performs patient care hand-off with Discharge nurse following center policy. Post-op follow up is completed by center's staff.