We’re already into the third month of the year, but it’s still the right time for office-based surgery centers to take a moment to reflect on last year, assess the current situation, and look ahead. The past, the present, and the future. There is one essential plan that should be examined and implemented in the same fashion: Quality Assessment and Performance Improvement (QAPI).

The Accreditation Commission for Health Care (ACHC) Office-Based Surgery Standards Manual addresses the need for addressing quality and performance and preparing the appropriate reports.

Standard 04.00.01 – Quality Assessment and Performance Improvement

The Past: QAPI

Standard 04.01.06 End-of-Year Quality Report states: “The organization must write an annual end-of-year report as an integral part of the QAPI Program, based on the annual plan, which details all quality activities and their progress or resolution during the year. The report must be submitted to the governing body for review and approval.”

The Present: QAPI

Continuing with Standard 04.01.06 End-of-Year Quality Report: “The annual quality report serves as the basis for development of the subsequent year’s annual plan.”

The Future: QAPI

Standard 04.01.01 QAPI Plan states: “The organization must have a written quality plan that details how quality activities will be performed.” Annually, the plan is to be approved by the office-based surgery center’s leadership.

The QAPI Plan describes how indicators will be identified, data gathered and analyzed, analysis findings used, corrective actions taken, and corrective actions evaluated. The plan describes in detail the annual activities for each department or group within the organization.

The plan must address, at a minimum:

• The quality measures for contractor services and how they will be monitored.
• Implementation on an ongoing basis.
• Use of quality and patient safety indicators that reflect appropriate prioritization.
• Indicator data to be collected, how it will be collected, how frequently it will be collected, etc.
• Uses of the data collected and analysis to improve the organization’s performance.
• Evaluation of the effectiveness of corrective actions.
• Oversight responsibility for QAPI activities, either by an individual with appropriate leadership authority or a committee. If the organization has a QAPI committee, the composition must include, at a minimum, representatives from leadership, the professional staff, and nursing, along with others who contribute to the organization’s operations.

The plan provides for review of at least the following:

• Scope and quality of services provided, including contractual services.
• Medication errors.
• Unanticipated event reports.
• Selected patient safety indicators (e.g., burns, falls, wrong site, etc.).
• Effectiveness of pain management.
• Infection prevention and control.
• Patient death.
• Unplanned patient transfers/admissions.
• Blood transfusions.
• Patient satisfaction survey results.
• High-risk, high-volume, and problem-prone areas.
• Incidence, prevalence, and severity of problems in those areas.
• Health outcomes, patient safety, and quality of care.
• Patient/family complaints/grievances.
• Healthcare record reviews.

Annually, the plan must set priorities for its performance improvement activities that focus on:

• High-risk, high-volume, and problem-prone areas.
• Incidence, prevalence, and severity of problems in those areas.
• Health outcomes, patient safety, and quality of care.

Here to Help

If you have questions or wish to access the most recent ACHC Office-Based Surgery Accreditation Standards Manual, contact your Account Advisor or email us at [email protected].