Unlocking Excellence: Quality Improvement Studies for ASCs
Whether you strive to enhance patient safety and satisfaction, optimize efficiency and drive financial success, or meet accreditation standards with ease — Quality Improvement (QI) studies can help you meet these goals.
The majority of ASC professionals are familiar with QI studies and what they can do. However, when you’re running a busy surgery center with all of its many activities, it can be difficult to take time to concentrate on QI. That said, QI won’t bring you desired results without producing measurable improvements in services and patient outcomes. And this can only be achieved through continuous positive action among all levels of your facility’s workforce.
To understand where to begin with QI studies and what implementation strategies work best, we invited two expert speakers to our recent webinar, Unlocking Excellence: Quality Improvement Studies for ASCs, to share their professional advice and answer the audience’s questions.
John Goehle — the owner of Ambulatory Healthcare Strategies, a regulatory and compliance oversight firm, the host of the ASC Podcast, and an accreditation surveyor with AAAHC.
Sarah Rea — a healthcare consulting manager on the clinical revenue cycle management team at Crowe, specializing in charge capture optimization in outpatient facilities and in internal audits to ensure compliance. Sarah also has 8 years of experience as an operating room nurse and 2 years of experience as a Director of Nursing.
Why do surgery centers need Quality Improvement studies?
John Goehle: QI studies are important from an accreditation, certification, and licensure standpoint. They’re written right into the CMS conditions for coverage, interpreted guidelines, and, of course, all the accreditation organizations require benchmarking and QI studies, and the two of them are kind of tied together.
We should point out that the term QI study tends to be focused more on the AAAHC environment because they actually use that terminology. If you’re only a certified organization, and you don't have accreditation, then the proper term actually is QAPI or a performance improvement project. Many, if not most, accreditation organizations (other than AAAHC) use the term performance improvement project.
There is some confusion among people that are not terribly familiar with QAPI, or just get into quality improvement, that quality improvement studies, or performance improvement projects, are the quality improvement and makes up the entirety of quality improvement, which is not the case.
QI studies are important, but they're only a component of the QI environment, the rest being ongoing QI activity. So one of the questions we always asked was — do you thoroughly understand the difference between a QI activity and a QI study?
QI activity is an ongoing activity that, even if you find that you're doing great stuff, you continue doing that activity. Whereas QI study is something that you keep doing it until you fix the problem, and then you move on. So QI study is never meant to be something that keeps going.
Ashley Poulos: Do you consider QI studies to be just as important as doing the monitoring?
John Goehle: I think QI studies are important in that you have to do a QI study when you identify a problem that's going to require outside research as well as gathering data. That's really the crux of a QI study compared to an activity. In activity, you're just gathering regular information. With the QI study, you identify a problem through other monitors that you have going on, and then you dive deeply into it by gathering data, doing research, and then trying to find a solution.
Ashley Poulos: With the research and everything, do centers usually use external sources to find research? How does it normally work?
John Goehle: Absolutely. That's one of the requirements is that you do research, you gather information through one of the many benchmarking activities that are out there to identify standards. For example, what the average wait time is, if you’re doing a wait time study. Or if you’re delving into nausea and vomiting, you need to get some data from professional organizations on what typical nausea and vomiting rates are after a procedure. Those are only things that you can get from doing some outside research, either through Google search or other available resources. I think AI is going to play a major role in the future in gathering that type of information and doing that type of research.
Biraj Patel: Is there any kind of standard for this information when you look at outside research, or can you just go to Google?
John Goehle: Excellent question, because we all know that there's a lot of misinformation out on the Internet. Whatever you're searching for, you have to make sure that it's a trusted resource. And to that point, places like Becker's ASC tend to provide a lot of good information. They don't do major research, but they often quote, or they gather information from organizations that have done that type of research.
And, of course, anything from the ASC Association, the major organizations, and the specialty organizations. I think the specialty organizations in particular, like the American Medical Association, the Anesthesia Association, all of those provide a lot of great information that we can use in this. But you don't want to just use a Google search and go with the first thing that shows up at the top of the screen.
Ashley Poulos: Is it required to have external benchmarking to do a QI study, or can it just be something that you're improving your own standards?
John Goehle: Some accreditation organizations want to see that. The only one that kind of mandates it is AAAHC. One of the questions that we, as surveyors, ask during a QI study is whether one of the studies performed in the last year was based upon external benchmarking. So there definitely is an expectation that not only are you seeking sources of external benchmarking, but you're using it for at least one of the studies that you have.
But to your point, Ashley, internal benchmarking can be just as good. One of the arguments I make all the time is that comparing yourself against yourself over time can be an extremely valuable resource. Especially as you mature, and you're looking into ways to get back to where you might have been before, or to improve what you're already doing — that's great.
Ashley Poulos: Do you find that a lot of times it seems to be the same areas that are being benchmarked? Like handwashing, for example. Is it harder to find different opportunities based off the external benchmarking?
John Goehle: Yes, and I’ve been frustrated in the past. I was involved halfway through the ASCA benchmarking and outcomes monitoring program, where we worked with ASCA to develop the financial measures. A couple of years ago, I tried to add 4 additional measures, but you have to go through all these committees to get to a point at which you are able to get something approved. And none of those measures were actually approved. And one of the reasons for that is that it's already tough enough for these benchmarking organizations, like ASCA, to gather that information and get the people to submit this information. They don't want to spend more than 10 minutes on gathering and entering that information.
So to that end, we have to be very careful about the sources we have and recognize that the information is going to be limited.
Another example is financial benchmarking in ASCs. Around 2010, my company was involved in a financial benchmarking study that was going to result in a 100-page-long wonderful book of all these statistics. But we were asked to pull it at the last minute, basically because the information in there would’ve run contrary to their goals of trying to prove to CMS that we needed to increase Medicare rates, as it showed that they were making money in surgery centers. And any profits that a surgery center might have would probably run afoul of the government's goal of pretty much breaking our backs on the financials.
Ashley Poulos: For a center that's new, are they required to have QI studies in place before their first accreditation? And if yes, how would they have it if they don't have any data to go off of, if it's like a surgery center that's less than a year old?
John Goehle: Yes, we do a lot of startups, and that is one of our biggest challenges. The simple answer to this is, if you’re going with a deemed status early option survey, with any of the accrediting organizations, and you go through the process and get approved, you'll have a three-year accreditation term (because that's the kind of the minimum for any of those organizations). But depending upon the level of information that was available to the surveyors during the survey, they might come back sooner.
So, sure, you can do without a QI study in an early option survey for, say, AAAHC. But if you didn’t have a QI study then, they might come back in order to see that you have a mechanism in place to do such studies. On its own, it might not be enough. There might be some other things, like maybe there's no QI activity because the surveyor showed up 2 weeks into your operations, and you only have 2 weeks of data. So it might not be on its own, but there is no requirement, certainly from a CMS standpoint, that you have anything prior to your certification. But it will definitely help you reduce a possibility of surveyors coming back.
Ashley Poulos: If the surveyors did come back — would we get notified?
John Goehle: If it is a deemed status survey, you will be notified that they will come back, but you won't be notified of the date. You would just have that window again.
Ashley Poulos: Could that hold up the approval, just not having the QI in place or no?
John Goehle: No, your certification will go through, your accreditation will go through. It's just that'll be contingent upon continued compliance with the certification requirements and the accreditation requirements.
Effective implementation of quality improvement initiatives
Ashley Poulos: How do we actually implement QI initiatives into the center, once we come up with the study that we want to do?
John Goehle: One argument I often make for QI studies is that some of the best QI studies I’ve seen, didn’t actually start out as a quality improvement study. Often it’s our wonderful nurses who identified a problem, did all the elements, and then fixed it. They just didn’t start out by putting it together.
Let’s say that somebody realized that there was a serious problem with wait time in a GI center. A nurse was doing the analysis, saw that people are constantly complaining about it, and asked what was going on. And then they find that doctors are telling all of their patients to show up at the same time, like 7 o'clock in the morning. So a nurse, or anybody else in the center, realizes this and calls the office to say that it’s not efficient, quotes the statistics, and proposes to at least put people in four different batches (7, 9, 11, and 1 o’clock), without even getting to the point of actually scheduling visits. That would greatly improve the efficiency, and reduce the wait time complaints based upon statistics they might have gathered.
So they go out, do some research to see what other surgery centers are doing, or what the standard is for bringing people in prior to surgery, maybe even looking at professional organizations — and they do this without thinking that it’s a QI study. But they’ve gathered all this information, they wrote off those emails, they did everything except documenting it as a QI study. As a surveyor, when I see this, I tell them that I’m going to my hotel tonight, and when I come back tomorrow, I want to see a written up QI study. And I’ll usually work with them a little on it so that they’re able to write it up. And those make fantastic QI studies.
So don’t forget to look into your activities. You do want to try to plan for these things, but remember that some of the best studies come out of activities that people did, not knowing what a QI study even was.
Ashley Poulos: And we're just doing it all along anyway. This kind of ties with what Sarah and I were talking about this morning. When Sarah came and started working for our surgery center in 2020, it was at an awkward time, I would say. There were many variables going on, and the paperwork was not in line there. And Sarah came in and was able to get our QI studies in place.
Sarah, when you came in, did you find that we were already doing the activity or was it a situation where you found an area that we could improve? Or what was your direction in that?
Sarah Rea: There's kind of a twofold answer there because it was a unique time. I came in and two weeks later we had a survey, so that was interesting. But I was able to leverage the results from that survey to identify points of deficiencies, and from there say which deficiency is going to be best turned into a QI study.
We were lacking in specific areas of documentation which we found there were trends in providers and XYZ that went into that, but we knew that it was a big area of opportunity. But we also wanted to be mindful of not only is this QI study improving quality, and making sure that we're following the accreditation guidelines, but how it is going to improve our center overall, like efficiency, cutting costs, and all of that.
We knew that implementing this preoperative to perioperative handoff tool would not only make sure that we had all the documentation in place before the patient went into the OR, but also would reduce duplication of efforts for finding that documentation. We wanted to make sure that there was a clear line of communication in place, and to just streamline everything to reduce duplication of work between nurses on the pre-op side and in an OR.
How many studies are surgery centers required to have per year?
John Goehle: From a CMS standpoint, it actually specifically states that it's based upon the needs of an organization and the complexity of the case. I'm not quoting exactly, but there is no standard number.
AAAHC doesn't have a standard number either, except for an expectation that you at least have two QI studies that you submit to them within a three-year period. Just as a rule of thumb, we usually look for two studies a year. But there is no mandated number, and I don't know of any accrediting organizations that have a mandated number.
That being said, maybe you've got a very small center. I have a center that's only open a day and a half a week. So we struggle to find a QI study and not much happens there, it's just a simple pain management center. So we really struggle to find things.
On the other hand, I've got another center — six room, 35,000 square feet. They've always got 3 or 4 QI studies that go on at the same time. And there's an expectation, based on the complexity of that organization, that they're going to be doing probably 5 or 6 QI studies a year. But again, you're not going to find an accrediting organization requiring a certain number.
QI study vs. QI activity
Ashley Poulos: If we're doing a QI study, and we keep making changes based off of our results, do we start a new QI study? Or is that a continuous QI study?
John Goehle: If you have a QI study that just keeps going, for example, for over a year, you probably converted that into a QI activity. I’ve been a surveyor for 23 years, and back in the beginning it was almost an expectation that every center would have a QI study on hand hygiene. I still see those studies, they’ve been going on for 23 years, and they still haven’t solved the problem. And they never will because there is no permanent solution to that type of problem.
By using the term continuous QI study, you’re describing a QI activity. QI study is something that’s researching a specific area, where you get very into the weeds. The expectation is that you identify the problem, identify some solutions, test them to ensure they work, and then you move on (maybe after a couple of renditions, but you move on).
QI study length
Ashley Poulos: How long does a QI study usually take? Does it typically last less than a year, or can it be longer?
John Goehle: It varies very dramatically. Especially in high volume centers, I found that you could utilize one week of data. Like with wait time. If you’re a very high volume organization, you can gather data for a week in February, implement some changes, look again in April, introduce some additional changes, then do another followup in June, and then at the end of June you can be done with the study. And that’s only 2 restudies within that time frame, and it was only four months old.
On the other hand, you might find something that's very complex and requires a lot of data gathering that you have to do over a longer period of time, and that could be carried out a year. I would generally not consider anything over a year for a QI study. If you can't solve a problem in that period of time, then you're probably a hospital.
How to collaborate on a QI study?
Ashley Poulos: Is it usually just one person that's doing the QI study? Or does it work better when we have a bigger group that's involved in it, rather than just one person leading the way?
John Goehle: There's reality, and there’s what you'd like. We love bringing everybody together and putting a system in place where everybody is sharing information, and you got a good group of people that come up with different ideas. But in the end, that's just not the way we work. We're so challenged right now with finding people to just do their job, just to be able to provide care, that they don't have time to do other things. We might have had that luxury in the past, but the reality today is that we're very starved for time to be able to do it. So I think in the end it is usually one or two people, typically someone in a leadership position, who does that.
Sarah Rea: I think that it’s pretty lean who is involved in the actual documentation and data gathering. But it is important to involve all staff members in the study itself — giving the background, explaining how this is going to benefit them, making them feel a part of it, so that you're not barking data at them, saying “You’re deficient in this, and we're doing a study on it.” Explain the why behind it, how it’s going to benefit their day-to-day, and make their jobs easier.
Ashley Poulos: What about getting involvement from the surgeons? Oftentimes when you’re making a change, there can be resistance. How can you get the surgeons on board when you have to make these changes?
Sarah Rea: The way I phrased it was that this is going to improve the time between pre-op and OR. You need to think about how you can frame it to sound like it's a benefit to them. If we're saying it's going to increase throughput to the OR by reducing time between the pre-op space to the OR space, they're going to be on board with it. If you're going to also back it up with compliantly, and that you have ongoing surveys, they're usually more receptive to that.
So it's just about getting a little creative with the words. You wouldn't say that exact thing to an OR nurse, for example, because they may not be as stressed by the fact that there's a longer time to get into the OR. So phrase it differently for your different audiences.
Ashley Poulos: Have you gone back to the surgeons to show how it worked and where the benefit was?
Sarah Rea: Usually, yes. And John, you talked about this at the beginning. What we did at our center was included in our QAPI meetings. And we made sure that a lot of the surgeons, or the providers, or investors were aware there, and then we also would post the results of the study and the benchmarking goals as we hit those milestones.
Documenting a successful QI study
Ashley Poulos: How do we go about putting everything on paper so that we're compliant and to show our hard work?
John Goehle: There are different formats for documenting QI studies, but my favorite one is the AAAHC format, which is a 10-step process. It’s very logical, and the steps are easy to go through. So even if I have a center that’s with the Joint Commission, I’ll still use the AAAHC 10-step process (I just won’t refer to it as AAAHC’s), because it makes you go through very logical steps.
You identify the problem, talk about why that problem is important to solve, and you identify a goal. A very important part of documentation is to identify a specific numeric goal to get to. Then you talk about the data you’re going to collect, and then you collect that data, analyze it, and determine whether you met the goal or not.
If met the goal, then your QI study is over. And if you didn’t, then you need to figure out the areas of improvement. What things might you do in order to improve the results that you had, to get yourself closer to the goal that you established? Then you educate and talk to the people and implement the needed processes. And next you go back, document a restudy, analyze the data again, and determine whether you’ve met the goal the second time. If not, then you keep doing that process.
The last part of the documentation, which is extremely important here, is that you got to communicate the results throughout the organization. Communicate it to your staff through staff meetings or bulletin boards. Run it through your Quality Improvement Committee. And then ultimately it has to get up to the governing body.
You have to show the governing body that whole process. That you studied this particular issue and you rectified it. The governing body has to be notified and that's going to be one of that reporting processes.
Ashley Poulos: Where do you find the most problems with documenting a QI study?
John Goehle: The biggest one I find as a surveyor is not clearly identifying a numeric goal, or setting an unreasonable goal. Wait time studies are the best studies that you can do because I don’t yet know an organization that has no wait time problem at all. And wait time studies can be easily researched and analyzed. And what I still find with these wait time studies is that the goal is stated as “reduce wait time”, or the goal number that’s unreasonable.
Another major problem that I found is that people start off a QI study wanting to look at tons of data. They gather it, put this data together in an analysis, and then come up with 17 different statistics that make it confusing to identify a solution to a problem.
QI studies have to focus on a very narrow item that can be easily researched and for which you can implement a solution. I think that we try too hard with these QI studies. Don’t get me wrong, I’ve gone to many organizations that didn’t try at all. But I’ve seen some very complex studies, and it didn't end up being very good because people didn't really focus narrowly on a particular issue that would have been worthy and easy to fix.
Ashley Poulos: Do you think we make it more complicated with the documenting of everything?
John Goehle: Yes, definitely. I think someone mentioned that AAAHC process is periodically faulted. And they do have a very rigid process, and my challenge with that is that sometimes people go through the process and can’t meet all the requirements in those 10 steps. However, they still end up with a product that solved the problem.
And even though they didn’t go through all the different steps that AAAHC lays out, when I see that type of study, I try to encourage them to keep doing those. I recognize that AAAHC looks for a very specific product coming out of it, but I never want to discourage people from doing some type of performance improvement project that results in changes, even if it doesn't meet all the requirements.
Ashley Poulos: So for AAAHC we do have to do the 10 elements?
John Goehle: You absolutely do.
Ashley Poulos: I think at least for us, and Sarah was witness to this, that we just have limited resources to be able to actually go through the process, document it, and do it correctly. Do you find that that happens quite a bit?
John Goehle: It does. We are regulatory compliance people. So we have a team that actually writes the QI studies for people. So realistically nowadays you're often having to call upon outside resources to do that, and it's becoming more and more common. I should point out that we can't do the study, but we can certainly document it. So if you have a consultant that you work with or a regulatory compliance division that works with your management company, often they'll have some people within those organizations that have a lot of experience in writing these things, and they are very good at the wording of that.
Leveraging data and technology to drive quality enhancements
Ashley Poulos: To kind of transition over to the technology side because I think in the last 5-6 years things have really proved as far as technology, even with EMR and being able to get better data, more thorough data on it. How has that changed since technology has improved?
John Goehle: I think one of the challenges that we have in the industry right now is that the implementation of EMR has been very slow. I don't know what the number is, but I've heard it's as high as 60-65% penetration of EMR, and as low as just below 50%. I feel it's probably lower than 50%, just given my experience with clients and the places that I visit.
And the challenge with those paper records is that gathering data can be very time-consuming. Having to go through those manual charts to pull all them, gather information, like when did the case start, if it's not written somewhere else, or in some other computer system. And EMRs definitely make that a lot easier.
The one thing that we haven't talked about is the pressure that we, as an industry, are under right now to gather quality improvement data and to be able to provide that data to our stakeholders. We know that our insurance companies want to have quality data. They want to know they're buying a product that’s high quality, and are working very hard to develop measures or to be able to compare one organization against another. And I think those organizations that have been slow to implement good quality improvement programs, slow to implement an EMR that would then gather that data, are going to be behind.
Realistically, to gather data to prove the quality of our services, we need to be able to gather information to rapidly put together good quality improvement activities as well as quality improvement studies. Hence, we're going to need access to that type of data, and that can only come out of an EMR. And when I say EMR, I'm not talking about those funky little systems where you take a paper record, and scan it up into an electronic system. I'm talking about real data that's entered with a computer terminal.
Biraj Patel: I think that when you have electronic data organized like that, it’s important to remain focused on your QI study. Because there's this possibility that you see all this data in front of you, and you want to do everything because it's all there. I think the important thing is to stay focused and solve a simple problem one at a time rather than a complex problem.
John Goehle: You're absolutely right. And that's what I was alluding to as one of the biggest failures I find with QI studies is when people overreach. But they need to keep it simple.
As a surveyor, I’m not looking for award-winning Qi studies because not many people can spend a lot of time to pull it together. And shooting too far often ends up with not having a goof study at all. So definitely, pick one simple statistic and then focus on that as part of your QI study.
Ashley Poulos: Have you found any QI studies involving technology to see if there are improvements?
John Goehle: We've had a couple of organizations that have just started up. We started doing QI studies on whether the information that we're gathering is actually useful for the outcome of the patient. When they use off-the-shelf EMRs, you can end up spending 45 minutes in pre-op for a 5-minute case. And I'm not kidding, I got a situation like that right now, where a facility is gathering information that’s totally useless for a particular case. For instance, a patient is asked if they’ve had any suicidal thoughts in the last 3 months, when they’re coming in for a urology procedure. That may’ve been a relevant question for a primary care setting. So a QI study is focused on ways to improve or to speed up the process of gathering this information and identifying things that don't really need to be part of the pre-op process — would be an example of a good QI study I've seen recently.
Sarah Rea: I know that we talked a lot about technology and EMR specifically and how sometimes those provide obstacles that we may’ve not considered in the QI study. But I want to also call out that they can be used to the benefit. It's much easier to gather data through electronic reports than when you're sifting through paper data. So just calling out that while it is challenging, especially going through the implementation of the EMR, it is beneficial in the long run to expediting the process.
John Goehle: Yes, Sarah, you actually bring up an interesting point. We've been talking about EMRs, but there's a lot of data that you gather, such as chart audits, peer review, information on temperature and humidity, which most of the time is just done with check marks on a piece of paper.
Now there are up-and-coming software packages out there that will computerize that process and also provide you with a lot of good information that could be used. So let's not just focus on those EMRs to gather data, but also think about information that's coming out of your billing system. Somebody mentioned here denial management is a good QI. I think that's an excellent example, and you should be able to get that out of your billing system. But even beyond billing and EMRs, I think the future is going to be about information gathering for things as diverse as incident reporting, chart audits, peer review, temperature and humidity logs, emergency logs and so on.
Addressing the audience’s questions
John Goehle: I saw a really good question about whether you should do financial benchmarking. There is no specific requirement from CMS or even the accrediting organizations on the types of benchmarking you need to do. Of course, it's much more common to see clinical benchmarking being done. However, I say it's like getting brownie points for you going that extra step.
Financial benchmarking is about being able to find operational things, be able to find ways to improve and reduce cost is extremely important. So even if it's not required, it's certainly something that's going to result in some operational and financial changes that would be very helpful to your organization. So you're not required to do it, and it is often difficult to get that information, but it's certainly worth the effort in bringing costs down.
Ashley Poulos: What are some financial benchmarks that you've come across?
John Goehle: I'll refer back to ASCA’s benchmarks, which are like the percentage of revenue for salaries expenses or for supplies expenses, and your employee benefit ratio. Another one would be actual clinical hours per case, which sound like a clinical benchmark, but it's actually also a financial benchmark, all because it has a direct impact on what your cost of care is. Anybody that's heard me speak, knows that I absolutely love clinical hours per case. I think it's the best benchmark out there in so many ways, both from a financial and operational standpoint.
Ashley Poulos: Sarah, have you found with your consulting that that's tied in to what you've been working on?
Sarah Rea: Yes, we do a lot with financial benchmarking and we've developed a software that many clients purchase, and we use to help guide our engagements with them and then they have access to those benchmarking statistics ongoing for the future.
Ashley Poulos: Is your data just specific to Crow, or is that anywhere? Like, is that external, so the other individual centers would be able to access it for their external benchmarking?
Sarah Rea: We source data from several clients and then we put out benchmarking statistics from that data that we collect.
Ashley Poulos: Someone asks — if you're currently doing JC and switching to AAAHC, what will be different in the QI studies? Is it just the format that we discussed?
John Goehle: It really is a huge change. We've done two or three Joint Commission to AAAHC conversions within the last two to three years. And what you find with Joint Commission’s performance improvement project processes is nowhere near as complex as AAAHC.
If you're going to go through that, I would recommend you to consider attending Achieving Accreditation, which has almost an entire day focused on QI studies, to get familiar with it. The nice thing about AAAHC is that there's this whole section in the back where they go through the 10-step process and all the requirements for that. They do really walk you through that process.
But there definitely is going to be a lot more work involved in that QI study than they were probably used to with the Joint Commission. I've actually been through Joint Commission surveys where they never asked me once for a performance improvement project.
Sarah Rea: Having gone through both, they're very different. I would say QI is a major focus of the AAAHC survey process.
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