We’re already in the second month of the year, but it’s still the right time for ambulatory 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).

Accreditation Commission for Health Care (ACHC) Ambulatory Surgery Center Standards Manual addresses the need for emphasizing quality and performance and preparing the appropriate reports.

Deemed Standards: 04.01.01 QAPI Plan and 04.01.12 End-of-Year Quality Report

Non-Deemed Standards: 04.01.01 QAPI Plan and 04.01.06 End-of-Year Quality Report

The Past: QAPI

Standard 04.01.12 End-of-Year Quality Report states: “The ASC must write an annual end-of-year report as an integral part of the QAPI Program, 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 quality report should also include how leadership played a supportive role in fostering the QAPI Program.

The Present: QAPI

Continuing with Standard 04.01.12 End-of-Year Quality Report: The annual quality report should serve as the basis for the development of the subsequent year’s annual plan.

The Future: QAPI

Standard 04.01.01 QAPI plan states: “The ASC must have a written quality plan that details how quality activities will be performed.” Annually, the plan is to be approved by the ASC leadership.

The QAPI Plan’s priorities should be set based on the following:

• 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.

Keep in mind, the plan should be developed based on the evaluation, outcomes, and recommendations from the previous year’s plan. Finally, it needs to be reviewed and approved by the governing body.

Annual review

Additional annual reviews, testing, and/or inspections must take place and include but are not limited to:

• Accounting audit (Standard 01.01.05 Accounting System).
• Written notice of operations with the local hospital (Standard 01.02.02 Hospitalization and Transfer Requirements).
• Patient rights review and monitoring (Standard 02.00.02 Administrative Leadership Responsibilities).
• Fraud and abuse audit (Standard 02.00.05 Fraud and Abuse Assessment Procedures).
• Human resource (HR) policies and procedures (Standard 02.01.01 Human Resources Policies).
• Staff training (Standard 02.01.07 Staff Training).
• Employee evaluations (Standard 02.01.09 Employee Evaluations).
• Staff competency (Standard 02.01.10 Assessment of Staff Competency).
• Emergency exercises (Standard 07.03.02 Emergency Exercises).
• Moderate sedation training and competency (Standard 11.01.04 Non-Anesthesia Professional Supervision of Moderate Sedation and 11.01.05 Non-Anesthesia Professional Administration of Moderate Sedation).
• Malignant hyperthermia training (Standard 11.03.02 Malignant Hyperthermia Policy).
• Radiation exposure (Standard 14.02.03 Radiation Exposure Monitoring).
• Inspection of aprons and other shields (Standard 14.02.04 Periodic Inspection of Equipment).
• Inspection of emergency eyewash stations (Standard 15.04.06 Emergency Eyewash Stations).
• Facility demographic report (FDR) (Standard 16.00.06 Facility Demographic Report).
• Emergency lighting test (Standard 16.01.09 Emergency Lighting).
• Interface device testing (Standard 16.02.02 Fire Alarm System: Testing).
• Transmitting signal testing (Standard 16.02.03 Fire Alarm System: Transmitting Signal).
• Fire pump (Standard 16.03.05 Fire Pumps: Annual Test).
• Water-based standpipes and hose inspections (16.03.07 Water-Based Standpipes and Hoses: Inspection and Test).
• Fire extinguishers (Standard 16.03.09 Portable Fire Extinguishers: Installation, Inspection, and Maintenance).
• Fire hose valves (Standard 16.03.10 Fire Hose Valves).
• Fire and smoke dampers if installed that year (Standard 16.04.03 Fire and Smoke Dampers).
• Overhead-rolling and horizontal-sliding fire doors (Standard 16.04.04 Overhead-Rolling/Horizontal-Sliding Fire Doors).
• Fire-rated door assemblies (Standard 16.04.07 Fire-Rated Door Assemblies).
• Fuel quality test (Standard 16.05.03 Generator Inspection).
• Supplemental load test (Standard 16.05.04 Generator Monthly Load Test).

Here to Help

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