Quality Improvement for the Ambulatory Surgery Center

Recognizing and prioritizing improvement opportunities

Every facility has opportunities for improvement in safety, efficiency, clinical outcomes, cost, or service. However, the capacity to undertake quality improvement initiatives usually is constrained, therefore departments must prioritize their efforts. Top priority should be given to the following: (1) gaps in care that pose a direct risk to patient safety or procedural outcomes (such as suboptimal processes or performance in preprocedure and postprocedure management of anticoagulants, antibiotics, hypoglycemic agents, and other medications; intraprocedural sedation practices; endoscope reprocessing; and major lapses in endoscopists’ procedural safety or performance); (2) measures required to ensure full reimbursement, such as licensure, deemed status, and other measures stipulated by CMS and accreditation organizations; (3) glaring issues related to patient dissatisfaction; and (4) quality measures promulgated by national and international organizations. Additional quality needs can be identified by attention to near-miss, never, or sentinel events (all of which warrant investigation for structural or process failures), patient complaints, and repeated mention on patient, employee, or referring physician questionnaires. Units must be aware of health system, state, and federal requirements for reporting (for example, wrong site of surgery) and implement processes to comply with these regulations.

Most well-managed departments already have addressed basic quality issues, allowing them to focus on other less glaring gaps in performance, including those unique to their specific environment or patient population. One useful practice for identifying improvement opportunities is to perform an assessment of lapses and bottlenecks in the sequential steps in care, from the referral process to scheduling, preprocedure exchange of information and patient guidance, preparation, check-in, procedure performance, recovery, dismissal process and guidance, and subsequent communication of results (called value mapping in Lean terminology). Ancillary aspects of care that tie into this linear process include periprocedural management of families, supplies, medications, pathology samples, procedural results, and so forth.

Quality metrics for endoscopy vary in their applicability to entire units vs. individual endoscopists and/or patients.⁸ Structural measures pertaining to the facility, personnel management, policies, and procedures are intended for application on the unit level; indeed, many are delineated in the CMS’s “Conditions for Participation” and, hence, are subject to scrutiny during accreditation surveys. The United Kingdom’s National Health Service uses a global rating scale (GRS)⁹ of 306 metrics in 21 major domains clustered among four dimensions (clinical quality, quality of the patient experience, workforce, and training) as a means of prioritizing improvement efforts and scoring service quality within endoscopy departments. Many measures scored by the GRS are encompassed in the training, privileging, credentialing, accreditation, and employment practices that we use in the United States. As previously noted, a multisociety initiative now is underway to identify unit-level quality metrics analogous to the GRS for application in our country, with consensus measures anticipated by late 2014.

Process measures are applicable at both the unit and the endoscopist level, such as those defining standard preprocedure, intraprocedure, and postprocedure care of all endoscopy patients, as outlined by the American Society for Gastrointestinal Endoscopy–American College of Gastroenterology work group noted earlier.¹

Because electronic systems also harbor data specific to individual endoscopist performance on most nationally defined measures, units should take responsibility for the acquisition and assessment of data and the quality oversight processes pertaining to individual endoscopist measures. This can be challenging, however, because many endoscopists practice at multiple locations. There is not yet a good mechanism to aggregate data at an individual level under this circumstance.

Quality measure reporting for the Centers for Medicare and Medicaid Services. CMS has developed a broad and all-encompassing quality strategy that strives to deliver enhanced and affordable care to achieve healthy individuals and communities. The strategy focuses on six National Quality Strategy (NQS) domains, including patient safety, person and caregiver-centered experience and outcomes, communication and care coordination, effective clinical care, community/population health, and efficiency and cost reduction. Toward these ends, numerous voluntary quality programs have been initiated, each with differing time frames, means of data submission, and financial inducements – most of which are evolving into financial penalties for nonparticipation. Two CMS programs are particularly pertinent to ambulatory endoscopy centers, which fall under the category of ambulatory surgery centers (ASCs).

The Physicians Quality Reporting System (PQRS) provides financial incentives to practitioners and groups that submit quality data via any of several mechanisms, including claims-based reporting, certified electronic health records, or participation in qualified registries, which is itself a PQRS quality measure. In past years very few quality measures specific to gastroenterology practice, and even fewer for endoscopy services, were available for reporting. This is gradually changing, however, with several additional measures adopted this year. Measures available for reporting in 2014 are listed in Table 1. Standards for successful reporting evolve each year, so annual reassessment of submission requirements is important. This year, most PQRS reporting options for the 2014 payment incentive (+0.5%) require a practitioner or group to report on nine or more measures from at least three NQS domains (listed previously) for at least 50% of their Medicare Part B fee-for-service (FFS) patients, or report all measures in one measures group on a 20-patient sample, most of whom are Medicare Part B FFS patients.¹⁰ To avoid the 2016 downward payment adjustment (−2%), participants must either earn the 2014 PQRS incentive or report on at least three measures covering one NQS domain for at least 50% of their Medicare Part B FFS patients.