10 Tips to Improve ASC Quality Measures and QAPI Success

Quality assurance and performance improvement (QAPI) are essential for ambulatory surgery centers (ASCs), but many organizations struggle to execute QAPI effectively. When QAPI studies are poorly designed or inconsistently conducted, ASCs risk regulatory scrutiny from the Centers for Medicare & Medicaid Services (CMS), potential accreditation issues, and . missed opportunities for serious improvement. A strong QAPI is program is essential for identifying gaps, driving measurable change, and improving patient outcomes. Fortunately, building a compliant and effective program isn’t as difficult as it may seem.

Follow these 10 tips to help your ASC achieve greater QAPI success.

1. Use Meaningful Data to Guide QAPI Priorities

Data is pivotal to identifying appropriate QAPI project topics. ASCs that effectively capture and analyze performance data gain clear insight into areas of strength and weakness, with the latter representing strong opportunities for focused studies. When CMS and accreditation surveyors assess an ASC's QAPI studies, one key component they evaluate is how the ASC determined that a topic warranted a study. Essentially, what did the data reveal about the surgery center's operations that justified the effort?

The good news for most ASCs is that they’re probably already collecting a tremendous amount of performance data, whether they realize it or not. Surgery centers routinely monitor financial metrics, conduct patient and staff satisfaction surveys, and complete incident and employee accident reports, among other data-gathering activities. Rather than reinventing the wheel, ASCs can often identify strong QAPI study topics simply by examining existing data and pinpointing areas where improvement is needed.

2. Select QAPI Topics that Support Measurable Improvement

ASCs typically only perform a few studies annually. As a result, each of those QAPI projects should have the potential to bring about worthwhile improvement, even if that requires more effort than other studies may entail. If you list five potential study topics, consider which are most likely to have the greatest impact on your patients or satisfaction, for example. These are the topics that deserve strong consideration for studies, as they can directly influence ASC quality measures and outcomes. ASCs may also consider projects that positively affect financial performance and revenue cycle efficiency.

3. Engage Frontline Staff to Strengthen QAPI Outcomes

When narrowing down potential areas of focus for a study, seek input from frontline staff and other key stakeholders, and engage them in the decision-making process. This will help achieve buy-in for the project and support successful adoption of changes made as a result of the study's findings.

4. Build Structured QAPI Plans to Ensure Timely, Compliant Studies

QAPI studies should be carefully planned and executed to ensure they receive the careful attention and follow-through required for proper completion. Develop a calendar for each QAPI study — outlining when the QAPI committee will meet, when a topic will be selected, when the study will begin, when results will be reviewed, and when the project is expected to conclude, among other key milestones — and do your best to follow the schedule. A well-organized calendar can also help streamline ASC quality reporting by ensuring that studies are completed on time and meet regulatory deadlines.

5. Routinely Assess Your ASC QAPI Program for Alignment and Effectiveness

Your quality program should receive ongoing evaluation. Here are some questions you should be asking yourself about your program:

• Are we monitoring the right performance areas?

• Are we studying the issues that matter most?

• Which studies are currently in progress, and which are on deck?

• Based on this year’s results, how many projects should we plan for next year?

Routinely reviewing these and other QAPI-related considerations will help strengthen both individual studies and your overall QAPI program. This ongoing assessment also positions your ASC to clearly demonstrate QAPI effectiveness to CMS and accreditation agencies.

6. Establish Clear Criteria for Completing Studies

Every study needs a beginning, middle, and end, and the end is just as important as the beginning. While there's value in extending a study when continued improvements are being implemented,, a study that never concludes provides little value to an ASC. When reviewing study results, the QAPI committee should discuss whether the study objectives have been met, whether it’s appropriate to formally close the study, or whether to continue.

7. Benchmark Thoughtfully While Keeping QAPI Tailored to Your ASC

It's only natural to want to know the types of quality studies other ASCs are conducting, and this information can prove helpful in identifying potential areas of focus. However, ASCs should avoid selecting study topics based solely on the work of peer organizations, as those topics may not reflect true areas of need within your own center. Instead, step back, look at your data, and confirm that the issues under consideration represent true opportunities for improvement. This approach helps ensure that each project is both appropriate and impactful, making it a strong QAPI topic for your ASC.

8. Align QAPI Goals with ASC Resources for Sustainable Impact

As already noted, several factors should be considered when weighing whether to proceed with a particular QAPI study. One additional factor is whether your staff has the capacity and expertise to complete the study effectively.

For example, a large-scale research study involving extensive data analysis may not be appropriate if your surgery center's staff lacks experience with that level of complexity. When choosing projects, avoid taking on studies that exceed your resources. Keep projects realistic, aligned with staff skills and operational capacity, while still ensuring they’re consequential and capable of driving improvement.

9. Expand Your Sources for Identifying Meaningful QAPI Project Opportunities

Potential QAPI study topics can come from many different sources, such as surveys (patient, staff, and surgeon), data analysis, physician and staff suggestions, online reviews, CMS and accreditation survey results, and OAS CAHPS survey data. By broadening where you look for ideas and remaining attentive to feedback and trends, ASCs can uncover valuable QAPI opportunities that might otherwise be overlooked.

10. Foster a Culture that Celebrates Improvement and Energizes Participation

When staff successfully complete a QAPI project — by identifying a problem, implementing interventions, and achieving measurable results — take time to celebrate their hard work and accomplishments. Doing so helps motivate staff to embrace innovation and continuous improvement. Over time, this culture of engagement and recognition often leads staff to proactively suggest new study topics and volunteer for larger roles — sometimes even leadership positions — in future QAPI projects.

Want to explore practical strategies for CMS and accreditation success? Check out our on-demand webinar, Achieving CMS and Accreditation Success: The Role Your EHR Should Play, for expert insights and actionable guidance.

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