Bernard McDonnell, DO, a retired physician and current surveyor for Healthcare Facilities Accreditation Program, identifies 15 questions surgery centers and other providers need to ask themselves to help ensure an effective and compliant quality program.
1. Do we know what quality is? "Ask yourself, 'Do we know what quality is?'" Dr. McDonnell says. "Be honest about it. If you don't know what it is, find out. It's essentially ongoing, data-driven quality assessment performance improvement."
If your organization does not have a quality program, start it immediately. "It's never too late to start one," he says.
2. Are we doing too much? If your organization has a quality program, determine how many projects you are working on now and assess if you're trying to tackle too many at once. "People get in trouble when they pick too many because then nothing gets done," Dr. McDonnell says. "Pick a couple projects and work on them — maybe it's just cancellations and transfers. Don't pick 10."
3. Is our quality program ongoing? "You have to do it all of the time," he says. "It has to be part of the ASC's mantra."
4. Is our program data-driven? "You can't just tell a story — you have to have data," says Dr. McDonnell.
5. Are we analyzing the data? Dr. McDonnell says ASCs must look at and analyze their data, and determine how they are going to improve the data.
6. Do we continue to analyze the data? Analysis of the data is not a one-time event, he says. ASCs should continue to analyze the data as more information is gathered.
7. Are we looking at data in a way to determine if we have improved? "That's what quality is — it's a way to analyze what you're doing to make what you're doing better, safer and more efficient," Dr. McDonnell says.
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8. Are we just doing case reviews? "ASCs need to do more than just perform case reviews for their program," he says. "You need to look at systems, areas like infection control, returns to the OR, transfers to the hospital, adverse patient events, etc."
9. What quality indicators and measures are we comparing ourselves to? It's critical for ASCs to compare their projects to other projects. "Go to the Internet and look for it — this information is available to you online," Dr. McDonnell says. "Look at the National Quality Forum, the ASC Quality Collaboration, etc. This will help you get your program going, allow you to see what other programs are and determine if the program you think is up to snuff really is."
10. Are we studying something we have perfected? "If you're looking at something and the results are 100 percent [compliance] over and over again, you have that one nailed," he says. "Put it to rest and start a new one. I've seen quality reports that for two years they report something at 100 percent. They don't need to do that anymore."
While it is not unreasonable to continue gathering data for a quarter or two after achieving a perfect score, once you've reached a full year of perfection, Dr. McDonnell suggests moving on and looking at a new area. "I think people get lulled into staying with one project," he says. "They don't want to change the indicators, change their projects. If it's doing well, it's easy. You have to have the courage to change when it's all good and move on to a new challenge."
11. Are we documenting our program? While the members of an ASC's staff who are involved in the quality program will know about the center's quality projects and data, it is critical for other staff members and physicians to know as well. "You have to put it up, post it where people can read it," he says. "Use a storyboard or spreadsheets. You have to celebrate the good, and the ugly you have to put up and identify it as something that needs work. Put it up where staff can read it — maybe the lunch room or break room. It does not have to be in patient areas."
12. Do we have quality minutes? "I think this often gets lost in surgery centers," Dr. McDonnell says. "It's important that when you have your staff meeting, you have a quality portion to it. It doesn't have to be two hours long. You talk about what you're doing and give results."
13. Do we bring the quality minutes and reports to the board? "That information must go to the board," he says. "The board is responsible for the quality of the institution and they must get that information."
14. Do we have an annual plan? "You start out in November and say, 'What are we going to do starting Jan. 2012? What are we going to look at?'" Dr. McDonnell says. "Make a plan and present it to the board for review and approval. There has to be a trail of knowledge." Remember the old adage: If you didn't write it, you didn't do it.
15. Do we have a designated quality officer? "Somebody at the surgicenter has to have some kind of training in quality," he says. "That doesn't mean they need to get a master's degree, but they need to be able to show they have some kind of training. And this person needs to be designated as the quality officer; there must be someone overseeing the quality program."
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