Building an Annual QAPI Plan That Drives Results

By: Rommie Johnson, MPH, PMP
Program Director

Posted: April 29, 2025

In an Ambulatory Surgery Center (ASC), a Quality Assessment and Performance Improvement (QAPI) Program is more than just a regulatory requirement; it’s a roadmap to enhanced patient safety and care quality. ACHC Standard 04.00.01 requires an ongoing, data-driven QAPI Program and 04.01.01 requires an annual QAPI plan that defines the activities to promote continuous improvement across all departments. The annual QAPI plan drives the QAPI Program forward by identifying metrics and priorities for improvement efforts that may (or may not) change each year. Your plan can be a powerful tool in fostering a culture of excellence, but Standard 04.01.01 was cited in 23% of surveys conducted during ACHC’s previous review period.

Program vs. plan: Two views of quality
Your QAPI Program is the bird’s-eye view of your comprehensive quality approach and a CMS condition for coverage (CfC). The QAPI plan is your annual guide to the specific actions you will take. ACHC Standard 04.01.01 requires annual review and approval of the plan. During this review, your ASC should assess trends in your existing data, set new priorities, and adjust performance improvement activities based on your organization’s evolving needs. An ACHC Surveyor will expect to see:

• Defined Indicators and Related Data
  Identify the specific metrics most relevant to your ASC’s organizational priorities – both patient related and operational. These indicators might include infection rates, patient satisfaction scores, incident reports, or materials costs. Once identified, the plan should describe the data collection method and frequency for each indicator.
• Data Analysis and Prioritized Corrective Action
  The QAPI plan must describe the processes for data analysis and the parameters that will identify acceptable performance. Internal or external performance benchmarks will give you concrete goals against which to measure progress. When goals are not met, the annual plan should identify priorities for improvement, corrective action to take, and a timeline for remeasurement to evaluate the effectiveness of the interventions.
• Oversight Accountability
  Each ASC has the flexibility to designate an individual with leadership authority or a committee with representation of clinical staff and administrative roles to oversee its QAPI activities. An inclusive approach promotes collaboration and a unified focus on achieving the plan’s annual objectives. Oversight responsibilities include approving the QAPI plan annually, reviewing data, and making adjustments as necessary to keep the program relevant and effective.

Common Pitfalls
ASCs that tap the full potential of their QAPI plan can improve the overall level of patient care quality and experience, as well as the efficiency and sustainability of the business. The most frequent challenges in implementing a QAPI plan that meets Standard 04.01.01 requirements include:

• Missing Quality Indicators for Contracted Services: ASCs frequently overlook quality indicators for contracted services in the QAPI plan. Solution: Conduct a comprehensive review of all contracted services and identify specific metrics to monitor performance in these areas.
• Irrelevant or Nonapplicable Indicators: Some QAPI plans list high-risk or high-volume procedures that aren’t even performed at the ASC. Solution: Ensure that your plan references only procedures and services your ASC performs.
• Lack of Specificity in Data Collection: Many ASCs fail to define how, when, and what data will be collected for each quality indicator, leading to inconsistent or incomplete data. Solution: For each indicator, specify the data source, collection method, and frequency in the QAPI plan.

Leveling up
To move beyond compliance to yield organizational benefits, consider these four strategies:

• Audit Your Data: Auditing data on a regular basis and across departments will help maintain focus on the most relevant areas and identify problem areas that need to be addressed. If you are consistently achieving your benchmark for a particular metric, you may want to reduce the frequency of monitoring, raise the bar for performance, or shift to another metric entirely.
• Set Realistic Goals: To offer staff a sense of direction and accomplishment, establish performance goals based on internal data trends (internal benchmarks) and industry norms (external benchmarks). Teams need to know what they’re aiming for!
• Focus on High-Impact Areas First: Prioritize high-risk, high-volume areas. These may be where patient safety and quality of care benefit the most from continuous improvement efforts.
• Implement Change Gradually: Facilitating change through incremental adjustment can increase chances of success and ensure more reliable measurement of progress. Multiple, simultaneous adjustments to a process make it hard to assess what really created change.

Finally, continuous staff training on the importance of quality indicators and data collection can also help ensure the QAPI plan remains an active part of your ASC’s daily operations.