Catalog Number : nad1658
Title : CMS Ambulatory Surge Centers: Quality Assessment & Performance Improvement, Patient Safety Indicators & Adverse Events
Speaker : Sue Dill

Webplay Recording Date : 1-19-2011
Webplay Price : $ 160 for two weeks viewing

Webinar Purpose:

CMS issued new Conditions for Coverage that every freestanding ambulatory surgery center (ASC) must meet if the ambulatory surgery center want paid for Medicare and Medicaid patients. The standards apply to all patients treated in the ASC including worker comp and patients with commercial insurance. These standards became effective on May 18, 2009 and contained 167 pages and 267 tag numbers. CMS states the board has over sight for all ASC activities including quality assessment and performance improvement (QAPI). The performance improvement is a very important section with CMS. This includes evaluation of medical errors and adverse events including the requirements of when a root cause analysis must be done. ASCs do not want to be caught to be out of compliance if CMS comes for a complaint or validation survey. Every department should be involved in the collection of PI indicators. CMS requires data collection of infection control indicators, grievances, clinical and patient safety indicators.

Target Audience: 

• Anyone who is involved in the collection and analysis of performance improvement data should attend this program.
• This includes:
  • All Department Directors
  • Performance Improvement Coordinator
  • Accreditation Staff, Chief Nursing Officer
  • Administrator
  • Nursing Management
  • Health Information Director
  • Physicians
  • Risk Managers
  • Infection Preventionist,
  • Legal Department
  • Compliance Officers
  • Patient Safety Officers
• CMS also says the Board is responsible for all aspects of performance improvement

Webinar Objectives:

• Recall the CMS changes to the ASC Conditions for Coverage that affect quality assessment and performance improvement
• Describe how to locate a copy of the ASC Conditions for Coverage
• Discuss that quality indicators should be collected on hand hygiene, infection control, grievance, quality and safety indicators
• Recall that CMS says that the Board assumes responsibility for all aspects of the ASC’s quality assessment and performance improvement plan

A Few of the Topics that will be covered:

• Introduction to ASC CfC
• How to obtain a copy
• How to keep apprised of changes
• CMS ASC website
• QAPI ongoing and data driven
• Identification of problematic events
• Identification of root cause analysis (RCA)
• PI Program
• Patient health outcomes data
• Patient safety and reduction of medical error
• Scope of the PI program
• Program activities
• High risk, high volume, or problem prone areas
• Sources of PI data
• Patient safety indicators
• Outcome indicators
  • HAI rates, Length of stay, readmission rate
  • Wrong site surgery, cases over 24 hours, wound infection rate
  • Patient fall in the ASC, patient burns, appropriate hair removal
• Process indicators
  • Time prophylactic antibiotics administered
• Tracking medical errors and near misses
• Patient satisfaction survey (patient experience with care)
• Outcomes monitoring program
• CDC and infection control indicators
• Incidence, prevalence, and severity
• Adverse events and medical errors
• System theory
• Opportunities for improvement
• Hand hygiene data
• Survey procedure of surveyor
• Questions and answers

Contact Hours:

This course has been approved for 1.2 Iowa Nursing Contact Hours. There is usually a reciprocal agreement between state associations to allow these to count for each state. If you have any questions, please ask your state association.

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.