ASC Quality Reporting: Meeting Requirements, Maximizing Value

Quality reporting is a necessary part of compliance for ambulatory surgery centers (ASCs). It’s how ASCs measure performance and demonstrate adherence to the standards required for patient safety and care. The results of ASC quality reporting can also directly affect the surgery center’s reputation among patients and the financial bottom line.

But what is quality reporting, and why is it necessary? Let’s explore these questions, what quality measures must be reported, and how your ASC can turn quality reporting into a competitive advantage.

Why ASCs Need Quality Reporting

The Centers for Medicare and Medicaid Services (CMS) requires ambulatory surgery centers to meet all program requirements under the ASC Quality Reporting (ASCQR) program. The program collects and reports quality measure data and makes that data available to the public. This enables patients to compare the quality of care provided in ASCs, which can help them make informed decisions about where they receive care and from whom.

Participation in the ASCQR program is mandatory, as established by federal law. As such, it must be included in every ASC’s compliance planning. If ASCs don’t meet the program requirements, they may receive a 2.0% point reduction to future Medicare reimbursements. But that’s not the only reason why ASCs need quality reporting.

Because it is reported publicly, any patient, provider, or payer can view quality measure data. This transparency can affect your ASC’s reputation and reflect on the quality of care it provides. By demonstrating compliance with the ASCQR program and continually improving care quality, ASCs can avoid expensive penalties, bolster their reputation, distinguish themselves in the field, and build patient trust and loyalty, which can benefit the bottom line.

What Is ASC Quality Reporting?

ASC quality reporting measures and evaluates the quality of care provided at ambulatory surgery centers. CMS defines a variety of quality measures that ASCs must collect data on. This data is then publicly reported so patients can understand how ASCs prioritize patient care and safety. The data comes from Medicare claims, surveys, and information that ASCs have voluntarily submitted.

The ASCQR program was authorized under Division B of Title I of the Medicare Improvements and Extension Act of 2006. It is a program developed and overseen by CMS using the Measures Management System, a standardized system for creating and maintaining ASC quality measures. Under this system, ASCs must report data using CMS’s standardized quality measures to receive Medicare’s full annual payment update. If program requirements aren’t met, the ASC may receive a 2.0% reduction in the fee schedule update for the payment determination.

The goal of the ASCQR program is to support patient decision-making and provider improvement. While it is mandatory for Medicare-certified ASCs to comply with ASCQR, with penalties for non-compliance, it’s more than just a regulatory hoop to jump through—it’s an opportunity to receive support and guidance in delivering a higher standard of healthcare quality. Plus, the public nature of the data provides transparency across the industry, allowing ASCs to develop more accurate, informed performance benchmarks to which they can aspire.

Which ASC Quality Measures Must Be Tracked and Reported On?

According to the ASCQR Measures Specifications Manual, ASCs in 2026 will need to track and report on the following quality measures for all patients (note that most are mandatory, while some are voluntary):

In addition to the above, the following quality measures are pulled from Medicare claims and enrollment data and only apply to Medicare Fee-For-Service patients aged 65 and older:

• Facility 7-day risk-standardized hospital visit rate after outpatient colonoscopy: Lower outcome rates are better.

• Hospital visits after orthopedic procedures: Lower outcome rates are better.

• Hospital visits after urology procedures: Lower outcome rates are better.

• Facility-Level-7-Day hospital visits after general surgery visits: Lower outcome rates are better.

Using Quality Reporting to Your Advantage

While quality reporting is mandatory for Medicare-approved ASCs, you can turn it from a compliance requirement into a competitive advantage by using measures to:

Identify Performance Gaps

Because quality measures are established well before you need to report on them, you can develop goals in advance and establish metrics you’d like to hit as an institution. And because ASCQR data is publicly available, you can create benchmarks based on similar ASCs in your market and conduct ASC quality improvement studies to better understand what you can do differently.

As you collect data to report on quality measures, compare the percentages to those you’ve identified as benchmarks or goals. This can help you identify performance gaps and opportunities and develop an actionable ambulatory surgical center quality improvement plan.

Improve Patient Safety

Some quality measures are directly tied to patient safety, such as patients who experience a burn or fall before discharge or within the ASC. If these rates are high or spike in a particular reporting period, it can provide an opportunity to make a targeted quality improvement plan for ambulatory surgery center staff that aims to better protect patients within your ASC.

Enhance Care Processes

Quality reporting benchmarking can help identify organizations achieving higher efficiency rates and better patient outcomes. This presents an opportunity to conduct ASC quality improvement studies and research how these organizations are succeeding, which may inform new strategies to integrate, new technologies to adopt, or new trends to follow.

By learning from peers in the industry and continually pursuing better ways to deliver care, ASCs can uplift one another and elevate surgical procedures and services.

Better Prepare for Surveys

Whether you’re trying to improve mandatory compliance or attempting to pass accreditation, quality reporting measures can inform how you approach surveys. Generally, the quality measures CMS develops serve as the standards to which all ASCs should aim to achieve. As such, they will likely align with other compliance or accreditation standards. This can help you create a more effective ambulatory surgical center quality improvement program and better prepare for surveys by anticipating what they may evaluate and how.

Increase Patient Trust

Sharing quality reporting data publicly may seem intimidating at first. After all, transparency is vulnerability—you can’t hide the truth when it comes to hard facts and numbers. But try not to think of it that way. Instead, view it as an opportunity to demonstrate positive results to patients.

Patients and healthcare consumers are critical, rightfully so. They’re putting their health and their experience in your hands. They want to know if they can trust the institution and its staff before going through any procedure, no matter how minor. By sharing data on your facility’s standards, quality of care, and safety, you can demonstrate to patients that you have their best interests at heart. You can prove your commitment to delivering safe, effective care at scale.

What Are Some Ways to Ensure Efficient ASC Quality Reporting?

Of course, before you can turn ASC quality reporting into an advantage, you must first master the reporting process. Here are a few best practices to ensure compliance success:

• Build effective internal processes and standardize them. As with any mandatory reporting, it’s best to be as thorough and prepared as possible. Identify when you need to report quality measures, how you need to report them, and what processes you need in place to gather the appropriate data for submission. Then, make these processes standard across the organization to ensure consistent adherence.

• Use technology, like EHRs and compliance software. Modern EHR and compliance software have come a long way, often offering features to capture anything and everything needed to report on quality measures. SIS Complete, for example, offers intuitive tools built specifically for ASCs to help you manage and meet quality measure reporting requirements, regardless of facility size or complexity.

• Train staff on why quality measures matter and how they contribute to outcomes. Staff must be trained on everything they need to document for quality measures and why. However, that’s not enough. It’s better to cultivate a culture of compliance within your ASC—one that encourages staff to contribute to better patient outcomes at every opportunity. Make it a point to prioritize quality reporting as a point of pride for every staff member, from surgeons to coders and beyond.

• Regularly review reported data for continuous improvement. The minimum is reporting on mandatory quality measures, but use these reporting periods as opportunities to improve patient care and safety. Review the data you submit on a regular basis, identify areas of improvement, and put together some actionable next steps in a quality improvement plan for the ambulatory surgery center as a whole to continually enhance operations and service.

• Stay up-to-date on CMS and accrediting bodies’ requirements. To avoid non-compliance penalties, always stay up-to-date on ASCQR program requirements. You can do so by following the QualityNet website and regularly checking it for current requirements. In addition, follow the CMS website and the major accrediting bodies’ websites to stay current with ASC standards and best practices.

Meeting Requirements, Maximizing Value

ASC quality reporting is required by CMS, and data must be shared publicly. However, don’t let this intimidate you. By following the best practices and strategies above, you can turn quality reporting from a requirement into a competitive advantage—one that demonstrates how your surgery center goes above and beyond to ensure the highest standards of patient care and safety are met and even exceeded.

Quality reporting can help your ASC maximize value. But to do so, it has to be embraced within the surgery center wholesale. It’s best to treat it as part of a larger culture of continuous improvement. Then, it’s less about scrambling to meet requirements and more about elevating services and the patient experience.

Frequently Asked Questions