OR Manager August 2022 - 26

AMBULATORY
SURGERY CENTERS
Continued from page 25
She asked them if physicians were
sending prescriptions for pain medication
home with patients. " If you're not
doing medication reconciliation, then
you don't notice that patients may be
taking Toradol at home, and you send
them home with a prescription with oxycodone
in it, " she says. " Do they know
they shouldn't take those medications
together? Has anyone in the organization
gone through that process with
them? " she asks.
" This is why having a process for
medication reconciliation is so important, "
Kleinhesselink says. " Think
through what possible scenarios there
could be and how your organization
would manage them. "
Chapter 5: Quality management
and improvement
Every organization must have a quality
improvement program, says Kleinhesselink.
It has to be organized, data-driven,
and peer based.
The foundation for quality improvement
includes:
AMBULATORY
SURGERY
ADVISORY BOARD
* Claire Everson, RN, CNOR, CCAP, Clinical Educator
and Consultant, Bloomfield Hills, MI
* Diane Fecteau, MSA, RN, CASC, NE-BC, Executive
Director, Maine Medical Center Scarborough Surgery
Center, Scarborough, ME
* Cynthia Hess, MSN, RN, FNP-C, RT(R)(CT)(ARRT), Director
of Nursing, Northeast Missouri Ambulatory Surgery
Center, Hannibal, MO
* Tracy Hoeft-Hoffman, MBA, MSN, RN, CASC,
Administrator, Heartland Surgery Center, Kearney, NE
* Beverly Kirchner, BSN, RN, CNOR, CASC, Chief Compliance
Officer, SurgeryDirect, Highland Village, TX
* program infrastructure
* communication of activities
* ongoing data collection
* studies
* benchmarking.
" Your program infrastructure is going
to be defined in your plan, and it needs
to be specific to your organization. You
want to look at what's important to your
organization, and you want to only collect
data that you really care about, "
she says.
" To do a quality improvement study,
you have to set a goal, take some kind
of action to achieve that goal, and the
goal has to be measurable, " says Kleinhesselink.
One area where people get
tripped up is they will measure data one
way in the beginning and remeasure it
later in a different manner, she says.
" For a goal to be measureable, you
have to have a number to measure, "
explains Dr Shapiro. " You can't simply
state that we're going to get better, or
that we're going to minimize or maximize,
or that we're going to improve.
Rather, you have to set a measurable
number, " he says.
AAAHC has a template to follow to
do quality improvement studies that
contains 10 steps, but there is no requirement
that organizations have to
use this template.
" We want to see those 10 steps,
but they can be written up in a different
order than the template. We will go
through and figure out if all the steps
have been done, " says Kleinhesselink.
Also, says Dr Shapiro, the study
does not have to be pages and pages.
" A really good quality improvement
study can be one page. Keep it simple. "
One way to identify whether or not
there is a problem that would warrant a
quality improvement study is, for example,
if problems keep coming up during
monitoring of key performance indicators,
if targets are not being met, says
Kleinhesselink.
The AAAHC triennial application requires
submission of two completed
26
OR Manager | August 2022
recently conducted quality improvement
studies. While onsite, the surveyor will
ask about these and other studies a
facility may have conducted.
Another part of this chapter is benchmarking.
Internal benchmarking also
can be a component of peer review,
and it can be looking at historical data
trended over time. External benchmarking
involves looking at similar organizations
for comparison or looking at nationally
recognized guidelines for comparison.
" A
lot of times, people think benchmarking
is just the collection of numbers
and comparative analyses, but
that is not what it is in quality improvement, "
says Kleinhesselink. " We have
to demonstrate that we looked at it,
were where we wanted to be, and
whether we had a problem. "
A subcategory of this chapter is risk
management. " You have to have a risk
management program appropriate to
your organization, " advises Kleinhesselink.
" To me, risk management is
protection. You are protecting your organization
by trying to do everything you
can to make sure bad things don't happen, "
she says.
Kleinhesselink notes that the biggest
issue she sees as a surveyor is a lack
of documentation. " When you interview
people, you can tell that they are doing
it, but the documentation doesn't always
happen, " she says.
Chapter 6: Clinical records and
health information
Chapter 6 says: " An accreditable organization
maintains electronic and/
or paper clinical records and a health
information system. "
Surveyors will want to talk with the
person in charge of clinical
records.
" Surveyors want to see how you've done
this. There's no one right way, but there
are elements that we expect to see, "
says Dr Shapiro. " Documentation is a
problem we see more than anything
else, " he says. " We want to see docuwww.ormanager.com
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OR Manager August 2022

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