Accreditation organizations expect ASCs to perform quality assurance performance improvement projects using a 10-step documented process, according to Surgical Information Systems Clinical Solutions Specialist Daren Smith.
Here are the 10 steps.
1. Define the project's purpose. Explain what issue the project is meant to resolve, how you discovered the problem and why it's significant.
2. Set a performance goal. Identify what you hope to achieve by the end of the project, explain the goal and convey its importance. Objectives could include reaching a benchmark, meeting a national standard or returning to a baseline performance measure. Make sure goals are specific, measurable, attainable, relevant and timely.
3. Describe the methodology. Give an explanation of how the project will be completed. The explanation should mention what data will be collected and analyzed, who is responsible for data collection and documentation, and how it will help reach objectives.
4. Gather evidence. Collect and document data. Use graphs, charts and spreadsheets to show how the data has been tracked over time.
5. Explain your analysis. Provide details on how the data was evaluated. For example, a focus group might have been formed to review the information, identify issues and raise questions.
6. Compare current performance to the performance goal. Evaluate the data collected and determine why performance differs from the goal, if at all. Then, brainstorm corrective actions.
7. Implement corrective actions. Explain the corrective actions chosen and note exactly how and when they will be executed.
8. Re-measure performance. Assess your performance to determine whether the corrective actions helped achieve the performance goal. Next, explain why you were successful or unsuccessful in reaching that target.
9. Record and communicate findings. Explain the project in an executive summary of a few paragraphs and determine what audience should see it. This could be a QAPI committee, board of directors or staff members, or all of the above.
10. Repeat. Even if the project was successful, run simple data analysis or continuously monitor efforts to ensure the corrective actions hold.