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CMS Reporting: How Has it Changed Quality Data Collection?

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In 2014, all ASCs with Medicare certification have new quality reporting requirements with which to comply. Starting April 1, ASCs will begin collecting applicable data on visual function following cataract surgery and on appropriate intervals for colonoscopies. In addition, ASCs will be required to collect data on staff influenza vaccination rates in October 2014.

These measures join those new in 2013, including the reporting of specified procedure volumes and use of surgical safety checklists. In addition, reporting will continue for the five original measures endorsed by the National Quality Forum in 2012 and brought under CMS' ASC quality reporting program umbrella: patient burns, patient falls, hospital transfer or admission, timing of prophylactic antibiotics and recording to wrong surgery (site, side, patient, procedure and implant).

While claims-based measures may be efficiently documented with EHRs, quality information reported via website portals is a different story. CMS has delayed web reporting to the National Health and Safety Network indefinitely. "ASCs still have to collect the data, they can't put it up on the web portal until next year," says Jennifer Searfoss, JD, CPME, CEO of Searfoss Consulting. "This affects all ASCs, even if the new measures are outside of their scopes of practice. They still have to report them, even if they don't perform cataract surgeries or do endoscopy. The idea of standardizing quality metrics is great, but taking it too far creates ridiculous problems, if you really begin to think about it."

According to Michael Patterson, president and CEO of Quad Cities, Iowa-based Mississippi Valley Health, and Missy Soliz, RN, manager of quality and materials for MVH, for ASCs to whom the new measures do apply, successful reporting depends greatly on physicians offices' participation. Cataract surgery data demonstrates the difficulty ASCs may encounter because of this arrangement. The fact that the measure isn't mandatory reveals a lack of standardization in the tools and measurement techniques used on cataract patients, something CMS has recognized.

As it stands now, CMS' Specifications Manual says in lieu of physicians offices checking cataract patients' vision, ASCs should undertake the task, which is difficult without clear expectations and communications with physicians offices.

While the other new measures may present similar challenges to ASCs in their quality reporting endeavors, the process isn't all hassle. "The best thing about the new system is the implementation of the sampling methodology with the new measures. This will alleviate some of the burden in collecting and reporting the data [we were seeing before]," say Mr. Patterson and Ms. Soliz.

Indeed, some networks of ASCs have excelled in data collection and quality reporting. The Iowa Association of Ambulatory Surgery Centers (of which Mr. Patterson is president) announced in December 2013 it met all of CMS' quality reporting requirements. "The Iowa Association of Ambulatory Surgery Centers was developed in order to facilitate communication and best practice sharing among those member facilities. We often share and encourage other centers to reach out to each other in order to ensure we are meeting and exceeding the quality reporting expectations established by CMS," says Mr. Patterson.  

For ASCs who may not be in a similarly supported network, Ms. Searfoss recommends treating the new quality data collection process as an opportunity to retain accreditation and identify potential workflow issues. "[The measure collection] changes can create a tumultuous change in workflow. That's why we attached it to accreditation — so staff members don't question the 'why' of the practice, it's simply part of how the ASC is accredited. We approach [measure collection] as though it were meaningful use, by helping staff establish the habit," she says.

Her biggest concern is that the measures aren't meaningful for some ASCs. "Trying to prove to physicians or owners that some of these quality measures are anything but busywork is really difficult," she says. "This is an opportunity for all ASCs to push on the government to come up with meaningful measures that will actually improve care, rather than investing in a workflow process that promotes busywork."

In the mean time, for ASCs struggling to meet CMS' quality reporting requirements, Mr. Patterson recommends a similar strategy as the one taken by Iowa Association of Ambulatory Surgery Centers ASCs: "I would recommend seeking out those facilities and organizations that have demonstrated an ability to meet the requirements," he says, noting a partnership with a proven ASC management company may also be beneficial for access to much-needed resources in streamlining the quality reporting process. "As the industry gets more complex, ASCs will need partners to help guide them through the changing landscape of operations, quality reporting and regulatory compliance," he says.

More Articles on Accreditation & Patient Safety:
The Surgery Center Accreditation Checklist: Most Commonly Overlooked Items
What Are the Biggest Barriers to Staff Influenza Vaccination?
AAAHC Names Tom Tassone Director of Health Plans

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