Accreditation surveyors are looking for quality improvement projects that really make a difference for ambulatory surgery centers. This means going beyond just measuring quality, cost and efficiency areas where the center achieves 100 percent; it means identifying areas for improvement and developing solutions.
The Accreditation Association for Ambulatory Health Care requires ASCs to complete at least two 10-step QI projects per year as well as several smaller projects that will contribute to the efficiency of the center. Medicare and other certification agencies are also interested in meaningful quality improvement and want to see ASCs always strive to be the best they can be.
"I really think people need to integrate their quality improvement projects into the bones of the center," says Facility Development and Management COO Ellen M. Johnson. "There is always room for improvement; you are always assessing processes and from there you can identify your next opportunity, create an action plan, institute changes, evaluate the results, tweak any identified weaknesses in the project and re-evaluate those changes. At the end of the day, people want to be proud of their centers and continually making improvements helps to achieve that goal."
Clinical
Clinical care delivery is one of the key areas for ASCs to devote improvement projects. The clinical area is divided into preoperative, perioperative and postoperative areas where patients prepare for, receive and recover from procedures.
"Each of these areas needs to be monitored constantly because there are always opportunities within each to improve," says Ms. Johnson. "It benefits the administrator, director of nursing, staff and physicians to identify initiatives within these areas."
Great opportunities to dig deeper into the ASC's benchmarks include:
• Length of time patients are waiting in preop before going into the procedure room
• Ensuring proper time-outs and patient safety checklists
• Staff and physician hand washing compliance
• Postop nausea and vomiting incidences
• Patient Recovery time
• Level of postoperative pain
Other areas of the ASC that should be monitored include cleaning and sterilization processes. Administrators and directors of nursing should also ensure that staff are knowledgeable in handling issues and/or emergencies.
Oftentimes there are more than one quality project being conducted simultaneously, usually in each of the center's areas. Additionally, administrators and directors of nursing should always encourage staff members to identify areas that could develop from monitoring into more detailed studies and action plans.
Business office functions and cost containment
There are several business office and cost containment processes and policies ripe for improvement. Most ASCs monitor these areas closely and will find opportunities for quality improvement projects among those falling below local and national benchmarks. Business office functions to monitor include:
• Scheduling efficiency and effectiveness
• Registration efficiency
• Pre-certification
• Medical records management
• Staff hours, overtime and salary
• Days in Receivables
"Look at your benchmarks to see how you are doing compared to other centers and then move ahead to either establish a 10-step study or a quality improvement project," says Ms. Johnson. "Administrators must be diligent in the operations of not only the clinical areas but also the business and administrative aspects of the center."
Additional areas for improvement within this area is to evaluate cost-containment efficiencies such as inventory management, implant standardization, and room turnover times. A typical QI study for implant management is case costing by analyzing the same specialty physicians at the center. Once the data is gathered and analyzed, the results are presented to the physicians during a specialty meeting. Often these results will encourage discussion among the peers and possibly effect changes in materials used within the evaluated specialty.
"We had success presenting these results to our physician at our centers. It started a beneficial dialogue that translated into meaningful cost-savings," says Ms. Johnson. "That wasn't a 10-step study, but it was based on something we had identified as an opportunity for potential cost savings while maintaining physician input. We consider ourselves to be stewards of our centers and to that end ensure that the physicians are getting information that is valuable. This resulted in the continuation of performing of cases in the most safe and cost-effective manner but in a vacuum without physician knowledge and input."
Patient satisfaction
ASCs often have an edge in patient satisfaction over hospitals, but there is always room for improvement. FDM centers take patient satisfaction seriously and when administrators see any negative trend in satisfaction scores or feedback, they investigate further to identify the issue.
"It might be communication-related and which could be fixed during the preoperative phone call," says Ms. Johnson. "Monitoring patient satisfaction scores often trigger new ideas for how the centers can improve."
High patient satisfaction is paramount and ASC leaders learn to balance satisfaction with efficiency. For example, a center Ms. Johnson worked with found the time patients were spending in their PACU was longer than the benchmark for their specialty. The ASC's DON investigated the process and obtained feedback from staff and patients about their experience. She found that patients were staying longer than necessary because they were enjoying how the center's staff cared for them.
"The procedures at the center were getting backed up because patients were staying too long in the PACU which impacted the rest of the center. Patients could not be brought into preop because there was no room in PACU for those patients recovering from their procedure. In turn, the waiting room became overcrowded due to the patients who were waiting to be brought into preop. This led not only to patient dissatisfaction due to the long waiting time but to surgeon frustration at time delays.
"So the DON brought the staff together to brainstorm ways to ensure that patients continued to be happy with their care but also leaving PACU at the appropriate time." Ms. Johnson reports that this brought about an improvement in patient experience. Without the analysis, the prior process would have remained in place thus perpetuating a less than optimal business and patient satisfaction experience.
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