Quality 101: Quality Management Improvement Program in aSingle-Specialty ASC


Quality 101: Quality Management Improvement Program in a Single-Specialty ASC

By Gayle R. Evans, RN, CNOR, MBA, CASC

Managers and administrators agonize over the requirement to implement a meaningful quality improvement program in an ambulatory surgery center (ASC). It is especially trying in a single-specialty center where there may only be one or two physicians. Accreditation agencies consider the following programs part of the quality management program:

  • Quality management (using a specified process)
  • Risk management
  • Physician peer review

The Accreditation Association for Ambulatory Health Care (AAAHC) requires that at least two physicians are part of their quality improvement (QI) program. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires the use of clinical practice guidelines for the surgery center. The quality program for the ASC should be consistent with the mission of the organization. Areas to be evaluated should include cost, patient care, and administrative functions of the center. The quality improvement program should review processes that are high-risk, high-volume or problem-prone to monitor. It is the responsibility of the governing body to monitor the QI program. The program should use rate-based indicators; these are the rates of occurrence which demonstrate a trend, exceed established thresholds, or are significantly different than indicators in other institutions. A second indicator is adverse-incident based. Adverse incidents are indicators that require an individual case review for every occurrence.

To improve the existing processes of patient care, to continuously measure the effectiveness of that care no matter the size of the surgery center, and to effectively develop the program tools to monitor the ongoing activities of the center are critical. These actions are especially important when one staff member has to perform many roles and cannot effectively remember the activities of one week, much less the activities within a quarter, when identifying frequency of occurrence. Tools that may be used in a center to track data in an ongoing manner include:

  • Variance tools
  • Patient satisfaction surveys
  • Critical indicator monitor
  • Peer review

Variance Tools

Variance tools are simple documents that allow a manager to monitor a trend. Indicators are identified to monitor the quality and appropriateness of important aspects of care. Indicators will identify high-volume, problem-prone, and/or high-risk processes. The indicators are objective, measurable, and based on current knowledge and clinical experience. Collaborative and specific indicators of both key processes and outcomes of care are designed, measured, and assessed in order to develop a study of their results. Indicators measured in a variance tool include but are not limited to:

  • Procedure delay (patient is late, physician is late, or instruments are not sterile)
  • Patient delay (lab work is not ready, patient is late, consent forms are not signed, there is a patient emergency, or the patient is a noshow)
  • Instrument/equipment delay (instruments are not sterilized, there is an equipment malfunction, there is a break in sterile technique, or equipment is not available)

Patient Satisfaction Surveys

Each patient will be given a patient satisfaction form at discharge and asked to complete and return it in a manner that is effective to successful retrieval. These forms will be monitored each month and a report given in quarterly meeting. The center should examine the process of collecting these surveys, aiming for at least a 10 percent return rate. The center should set its goal for achieving a specific return rate; these forms are critical because they reflect patients’ opinions of your center.

Critical Indicators

Critical indicators can be used to review specific functions in the surgery center process. Critical indicators are effective to evaluate specific items that cannot be tracked by any of the other tools, such as:

  • Extended stay in recovery
  • Extended length of surgery
  • Use of reversal
  • Excessive nausea and vomiting
  • Return to the operating room

Peer Review

Peer review is the most misunderstood process, especially in a small center. It is the physician’s responsibility to perform peer review and the center’s responsibility to report the results. Choose a reasonable number of charts for random review. In addition to the random review, peer review should include any patients who have experienced unusual occurrences such as hospital admission, elevated blood pressure, return to the operating room, excessive pain, etc. Peer review consists of looking for reasonable care given by the physician, using their documentation as a guide; this is why physicians need to review physicians.

The QI Process

All staff members must participate in the quality management and improvement process. Medical staff will be an integral part of the process and will have representation on the quality management and improvement committee. The facility’s quality management and improvement program will use appropriate analysis tools and statistical reporting to evaluate identified indicators. Reevaluation of quality improvement studies should occur consistently. Asimple QI process can be explained by using the “FOCUS PDCA” strategy for improving organization performance:

Find a process to improve
Organize an effort to work on improvement
Clarify current knowledge of the process
Understand process variation and capability
Select a strategy for improvement The cycle that can be used in the ASC is:


1. Determine data needed to monitor the improvement in the process

2. Determine indicators for the improvement-monitoring plan

3. During the planning process several issues should be resolved:

  • Why is this idea being monitored?
  • Who will be involved in the process?
  • What do they need to know to participate in the process?
  • What are the timetables?
  • How will the process be implemented?
  • What are the success factors?
  • How will the process and the outcomes be measured and assessed?


  • Collect and analyze data on improvement in the process
  • Make improvement changes/actions when indicated and appropriate

This step involves implementing the pilot test and collecting actual performance data


  • Establish decision/review points to determine the effectiveness of changes
  • Assess the effects of improvements
  • Analyze the improvement results

This step involves analyzing collected data during the process to determine whether the improvement action was successful in achieving the desired outcome(s). Actual test performance is compared to desired performance targets and baseline results achieved using the established process.


The team meets on a regular basis to determine what was learned. Tests or actions are repeated, if necessary, to ensure improvement. This step involves taking action:

  • If the pilot test is not successful, the cycle is repeated. Once the actions have been shown to be successful, they are made part of the standard operating procedure
  • The effectiveness of the action will continue to be measured and assessed to ensure that improvement is maintained
  • Report all activities to the governing body


All actions implemented will be restudied within a specified period of time to evaluate effectiveness.

  • Study will be reopened as determined by committee
  • The quality management and improvement process will be a part of orientation and annual training of employees


All quality management and improvement activities will be reported to the governing body.

  • The governing body will take appropriate action on the quality management and improvement activities as necessary

Annual evaluation of the quality management and improvement program should occur to determine the effectiveness of the program as part of the total surgery center appraisal. A written report of this evaluation is submitted to the governing body. This report includes:

  • Identified opportunities to improve care
  • Corrective actions taken to resolve issues identified and make improvements
  • Educational programs related to continuous quality management and improvement activities
  • Program changes planned as a result of the annual evaluation (changes in scope, organization, objectives, etc.).

Gayle R. Evans, RN, CNOR, MBA, CASC, is founder and president of Continuum Healthcare Consultants, Inc. and Quality Surgery Centers.


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