There are several reasons for ambulatory surgery centers (ASCs) to invest the time and resources in developing a robust quality assurance performance improvement (QAPI) program. The development, implementation and maintenance of an ongoing, data-driven QAPI program is a Centers for Medicare & Medicaid Services (CMS) condition for coverage. Accreditation organizations such as AAAHC and The Joint Commission include standards that address QAPI.
More importantly, QAPI programs have the potential to substantially improve clinical, administrative, and financial performance of your organization. However, when it comes to executing effective QAPI programs and their projects, many ASCs fall short. Why?
In this article, we have identified five common reasons why ASCs often struggle in finding success with QAPI and provide tips and advice to avoid these pitfalls in your future efforts.
Unable to identify priorities
There are many articles and discussion threads on ASC industry websites and blogs about finding topics for your QAPI projects. While these sites can be a good place to start, you want to avoid just picking a topic for the sake of picking it. A good QAPI activity topic for one ASC may not necessarily be a good topic for another. When identifying QAPI priorities, you should ask yourself two questions: 1) “What do I know, or suspect to be a problem?” and 2) “Why is it important for my organization to address this problem?”
No ASC is perfect, so with a little thought, I suspect you can come up with a number of areas of your operation that could be performing better. Make a list of areas where you believe problems exist. Then prioritize this list based on three criteria.
- Is this a high-risk, high-volume, and problem-prone area?
- What is the incidence, prevalence, and severity of the problem(s) in this area?
- What is the effect on patient outcomes, patient safety, and quality of care?
If your chosen problem area meets all three of these criteria, then you have a worthwhile topic for your ASC’s QAPI project.
Did not set goals
This sounds simple enough, but I often find that ASCs will start a QAPI project without a clear endgame. Without setting a clear and defined goal, you are simply going through the motions of a project that will yield zero improvements and you will fall into the common trap of monitoring performance as opposed to improving it.
To make sure you have a good goal for your QAPI project, I suggest using the SMART goal structure. SMART goals are goals that are Specific, Measurable, Attainable, Relevant, and Timely.
- S (Specific) – Is your goal narrowly defined? A broad goal will often need to be achieved through multiple actions or QAPI activities and cannot be accomplished at once.
- M (Measurable) – Is your goal something that can be measured using data? QAPI projects are all about numbers. If you can’t represent your goal using hard numbers or percentages, you do not have a good goal, or a good QAPI topic.
- A (Attainable) – Is your goal realistic? It’s great to set the bar high, but be honest with yourself. You want to make sure that your goal pushes your team while still being achievable.
- R (Relevant) – Does your goal meet your project's criteria? Does your goal answer the question your QAPI project is trying to solve in the first place?
- T (Timely) – Do you have a timeframe to reach your goal? Make sure that you hold yourself accountable to your goal with a date. Remember, be realistic, but a timeline will keep you and your team engaged and motivated.
Implemented more than one action at a time
If you try to address more than one issue at a time, you will not know whether your QAPI project action was successful. This mistake can be avoided with the S of your SMART Goal. Be specific! Do you remember learning about the scientific process in school? In order to provide scientific proof for your hypothesis, you need to conduct a controlled experiment (one in which only a single variable is tested at a time). Think of your QAPI activity in the same way: To be sure that the corrective action you are taking is affecting the area you have identified to address; all other variables must remain constant.
Lack of benchmarking data
This can be tricky. If you are new to conducting QAPI projects, or if you do not have anything in place to collect data at your ASC, it can tough to establish a reference point for comparison. However, there are many resources to help you out. The Ambulatory Surgery Center Association (ASCA) provides national clinical and operational performance statistics on topics such as clinical outcomes, staffing indicators, billing performance and more. These resources are discounted for ASCA members and can be accessed by clicking here. The AAAHC Institute for Quality Improvement also provides benchmarking data for use in quality improvement. Financial benchmarking data for ASCs is available through the Multi-Specialty ASC Intellimarker, which is developed by VMG Health, a healthcare valuation and transaction advisory firm. Other possible areas to collect benchmarking data are your state and local professional associations, colleagues, and industry blogs. Just make sure that the source of the data is reliable before you begin using it to benchmark against.
Did not collect baseline data
Before you start collecting baseline data for your QAPI project, you should consider the following:
a. Does the problem actually exist?
Make sure you aren’t being anecdotal or situational with your QAPI activity. Just because you perceive to have a problem does not mean it exists. Remember that QAPI is all about data, and remember the tip from identifying priorities. Ask yourself, “What is the incidence, prevalence, and severity of the problem(s) in this area?” If the problem is not happening regularly, or happened for a short time and then stopped, you can likely assume that the issue was an anomaly and does not require a corrective action.
b. How much data is needed to verify your baseline?
You will need to determine how much data you will need to verify your baseline. This will vary from ASC to ASC and from project to project, but it needs to be enough to see a trend or pattern. This is also crucial to your first consideration of whether the problem actually exists.
c. Can you express the frequency and severity as a number or percentage?
This consideration is determining if the problem is real or perception. A great example is with patient wait times. For example, let's say that you are receiving multiple patient complaints about waiting room wait times. However, after looking at patient check-in times, you find that patients are showing up an average of 30 minutes prior to your recommended check-in time. The issue is not that your wait times are long; rather, it’s that your patients are not following your instructions. This is the difference between qualitative versus quantitative data. Qualitative data is important for fixing issues of perception, but quantitative data provides hard proof of performance. In this example, your real issue is patient education — making sure patients understand the expected wait time and when to show up for their procedure.
d. How are you collecting or will you collect your data?
You need to have the tools in place to answer these questions, and you can’t do that without detailed organized records. Many ASCs still use paper records to document care, and while QAPI projects are not impossible with paper records, they can be more difficult and time consuming. Most ASCs have practice management software in place to record business and operational information. The reporting features within these solutions can be very helpful in conducting QAPI activities.
However, the most comprehensive and efficient way to collect data for QAPI projects is with the use of an enterprise software solution. You should consider investing in ASC information technology that includes a practice management solution, an electronic medical record, and analytics. These tools make it easy to collect and process business, financial, and clinical information specific to your ASC’s performance.