4 Steps to Implementing a Robust Performance Improvement Process
1. Consult AAAHC on performance improvement. Mr. Ollayos says the first step toward fortifying the center's performance improvement process was consulting AAAHC. By attending AAAHC’s Achieving Accreditation seminar, Tri-Cities was able to refine its performance improvement program.
"The AAAHC surveyors who conducted the seminar were also a tremendous resource for guiding a center into compliance with AAAHC standards," Mr. Ollayos says. "AAAHC's Institute for Quality Improvement also puts out some terrific bulletins on topics such as data collection for performance improvement studies and designing patient satisfaction surveys."
2. Implement an efficient and effective aggregation and analysis process. An ASC's performance improvement process is virtually ineffective if the data collected through incident reporting and other sources is not used in a manner that spurs measurable process improvement and change. One way to make great use of collected data is to perform aggregation and analysis using specific parameters.
"If we have variance reports identifying undesirable outcomes, we'll look to see if those outcomes are coming from physicians within one specialty, one specific physician or procedure or if it involved one piece of equipment," Mr. Ollayos says. "The key is to look for data that identifies where the problem is happening."
3. Exercise transparency. A key element of AAAHC's 10-step performance improvement process is to communicate the findings of performance improvement efforts to physicians, staff and the governing body. Mr. Ollayos says his surgery center sends a full "Performance Improvement Program Report" from its physician executive committee to its management board on a quarterly basis.
"Every meeting, there is a report on our performance improvement program, so we'll look at the number of cases performed, the benchmarking comparisons, patient satisfaction survey results, peer review, what the incidents were and the resolutions that resulted from those incidents," he says. "Then the physician executives will take that report to the full management board so we are able to complete the cycle of communication."
Performance improvement study results are also reviewed with staff at their monthly meetings.
4. Involve physicians in performance improvement. Another key component to an effective performance improvement program is physician involvement. Peer review is essential for an effective process and is required by AAAHC. Also, ASCs need to share outcomes data with physicians. Physicians can also be invaluable in helping design and analyze performance improvement studies.
"Whenever we have a physicians come up for reappointment, which is on a three-year cycle, our physician executive committee and management board look at the results of peer review, variance reports on post-procedure complications, infections, and hospital transfers, feedback from patient satisfaction surveys and any other additional reports to assess granting reappointment," Mr. Ollayos says.
Learn more about Tri-Cities Surgery Center.
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