Frequently Asked Questions
Benchmarking
Q: What is benchmarking?
A: Benchmarking is a process used to measure performance on particular criteria and to compare those findings to those of similar organizations. In general, benchmarking can be done in many areas, such as staffing, budget, performance in certain areas, etc. The benchmarking conduced on this website for surgery centers measures the quality indicators required by CMS as well as accreditation organizations such as The Joint Commission and AAAHC.
Infection Control
Q: Does a surgery center need to have someone function as an Infection Control Coordinator?
A: Yes, as a requirement of Medicare.
Q: What type of training is required for an Infection Control Coordinator?
A: An Infection Control Coordinator must be a licensed professional with training in infection control when appointed and needs ongoing training to stay abreast of changes/updates in Infection Control. Acceptable training has included live conferences/seminars and online courses.
Medication
Q: What do I do if a medication has expired and it is on backorder?
A: Leave the expired medication in the inventory for use and contact the manufacturer to assure its safety to be used. Make a note in the cabinet acknowledging the expiration. Keep documentation from supplier showing back-order, document that the governing body is aware and have the Medical Director sign.
Patients’ Right to Know
Q: What information about the facility must the surgery center give to patients?
A:
- Patient’s Rights
- Advance Directives Policy
- Ownership of the ASC
- Grievance Information
Physician Ownership of ASC
Q: What does the ASC have to disclose to patients related to the physician ownership?
A: The complete list of owners of the ASC must be given to the patient in writing and posted for the patient to view prior to surgery, along with alternative sites for service.
Quality Data Codes
Q: What are the quality data codes a facility needs to track for Medicare?
A: Began reporting in October 2012 on:
- Patient burns
- Patient falls
- Wrong site/side/patient/procedure/implant
- Hospital admission/transfer
- Timing of prophylactic antibiotic
- In July/August 2013 reported use of Safe Surgery Checklist and the number of certain procedures done (pre-determined by CMS by CPT Code)
Quality Improvement Studies
Q: What are some suggested topics for Quality Improvement (QI) studies?
A:
- Assessment of and response to Patient Satisfaction Surveys
- Hand hygiene observation and response
- Patient wait times
- Recurrent complications and follow-up
- Wrong Side/Site, Near Misses
- Clinical Record Reviews
- Medication Errors
- Testing or trial of new products, technology, or methods of care
- Staff concerns
- Wasteful practices
- Short or Long Term Goals
Q: How do I write a QI Study? (These follow the process outlined in the AAAHC Standards.)
A:
- State Purpose – Describe the problem and why it is significant.
- Goal – Identify a performance goal and compare with current performance in the area.
- Description of Data to be Collected – Describe the data that you will collect for the study and how you will collect it.
- Evidence of Data Collected – Describe what you actually collected. How many, what, and how? No conclusions, yet.
- Data Analysis — Briefly record your findings. Frequency, severity, and source of the problem.
- Comparison of Actual Performance vs. Identified Goal – Simply state “currently have X and the goal is Y”.
- Corrective Measures Implemented – What are they? How were they implemented?
- Re-Measurement – Describe the second round of data collected and how it was collected. State comparison of new current performance vs. goal for the QI study you are conducting.
- Additional Action Needed – Yes or No, Time Frame. Repeat steps until goal is achieved.
- Final Outcome – Statement of Achievement.
- Communication of Findings – How the results will be reviewed by the Governing Body and how it will be documented. Does any information need to be incorporated into educational activities?
