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10-Step Process for a Successful ASC QAPI Program

Daren Smith

November 27, 2017 By Daren Smith


surgery center roomWhile the various ASC accreditation organizations (e.g., AAAHC, The Joint Commission) have different standards they expect accredited surgery centers to meet, one area these organizations agree upon is how ASCs should approach quality assurance performance improvement (QAPI) projects. Surgery centers are expected to perform their projects using a 10-step documented process.

Here is a breakdown of the 10 steps along with analysis to help you complete meaningful projects that help deliver improvements to your ASC's operations.

  1. Purpose. Explain the purpose of the project and define the problem(s) the project is intended to help resolve. Include how you identified this problem and how is it important to your surgery center's operations, whether that be clinically, operationally and/or financially.
  2. Performance goal. Next, identify the objective of the project. By completion of the project, what do you hope to achieve? Include a short explanation of why you chose this goal and its importance. Are you hoping to reach a certain benchmark? Meet a certain national standard? Are you working to return to a previously identified baseline performance measure? When defining your QAPI goal, you should use the SMART goal structure. To learn more about the SMART goal structure, click here.
  3. Description. With the purpose and goal of the project identified, you should explain how you intend to complete the project. What is the data you will collect and analyze? Who is responsible for collecting and documenting the data? Why do you believe this data will provide the information needed to reach your goal?
  4. Evidence. The next step is to gather and document the data — i.e., provide evidence of your data collection efforts. This can include graphs, charts and spreadsheets. If you use a business analytics solution, you may have screenshots and other exported resources. These documents should demonstrate how data has tracked over time.
  5. Analysis. With data (evidence) collected and represented visually, it's time to explain your data analysis process. For example, you might note that your analysis included a focus group of people who came together, reviewed the data, identified important issues and raised various questions. Then you would describe the activities you intend to undertake to address the issues and answer the questions. This step is essentially a way to add commentary and color to the data collected.
  6. Current performance versus goal. You've collected the data, analyzed it, and identified the most relevant data points to your project's goal. Now you should look back at your goal (identified in step #2) to see how the data you collected compares to that goal. Work to determine why the data is different from your goal (if it is) and what are corrective actions that may help reach that goal.
  7. Implement corrective actions. With potential corrective actions identified in the previous step, it's time to implement some or all of them. Include an explanation of the corrective actions you will implement and the timeframe for implementation. Note what will actually happen when you implement the corrective action and when that will happen. For example, a corrective action may be education of staff and/or implementation of a new process. What do those actions look like, and how and when are they to be executed? When is the start date? After that start date, what is the end date, i.e., when you perform your re-measurement (step #8)?
  8. Re-measure performance. Once you have implemented corrective actions, re-measure your performance to see if you hit your target goal. If you did, explain why you think you were successful. If you didn't, note the reasons why you think that was the case.
  9. Record and communicate findings. This is where you're essentially wrapping up the project. You proposed that you had an issue and set a goal to resolve it. You then confirmed that you had a problem. You created and looked at the different analyses of your data, and developed what you hoped were corrective actions to meet the goal. Then you performed a re-measurement to determine how you were doing in meeting that goal.

Now it's time to determine what you need to communicate. Put together a summary that explains your project in just a few paragraphs (i.e., an executive summary) and determine who needs to see it. Depending on the structure of your ASC, this may be a QAPI committee, board of directors and/or staff members. There may be specific departments that should review and discuss this information.

  1. Repeat. Even if you find that your corrective actions were successful and allowed you to meet your goal, you're not necessarily done with the QAPI project yet. Depending on the type of project, you may want to re-measure your performance over a period of time to ensure you continue to meet that goal. This may entail running simple data analysis. It may require ongoing monitoring. What matters most is ensuring that your corrective actions hold and you hit your goal consistently. Repeat the QAPI project process until you feel confident you do not need to do so anymore.


Topics: ASCs, Ambulatory Surgery Centers

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