Guidance for Benchmarking Your ASC as Part of a Quality Improvement Program: Q&A With Dianne Wallace of Menomonee Falls Ambulatory Surgery Center

Dianne Wallace, executive director of Menomonee Falls (Wis.) Ambulatory Surgery Center, explains how the surgery center has implemented benchmarking processes as part of its larger quality improvement program to meet the standards set by the Accreditation Association of Ambulatory Health Care.

Q: What processes does Menomonee Falls ASC use to benchmark quality measures?

Dianne Wallace: On a quarterly basis, we have a number of quality indicators that our organization looks at. The four quality indicators we measure are cost, service, clinical outcomes and functional, which measures documentation and productivity. For example, in terms of performance measures for service, we have a set number of formal complaints per patient, percentage of patients that are satisfied with our quality of care and so on. For our outcome indicators, we measure the number of incidents or number of post-operative wounds or infections that a patient may experience. For functional measurements, we see if the facility is meeting national standards for operating cost-effectively. We also look at percent of cases that start on time and amount of total hours per case.

Q: Once the center has measured those aspects, what does it do with that information?

DW: We put together a profile and submit our data to the Ambulatory Surgery Center Association and compare our data to other ASCs that submit information. We also use the MGMA cost survey and compare our data with them. These profiles are also presented to our surgery center's finance committee, quality committee and governing body to show them how we fare in those benchmarks. We do this to compare our quality with local and national standards and ensure that we are trending in a positive direction.

For us, benchmarking is used as a basis for identifying areas of improving and that feeds into our QI program. It helps us identify if there are studies we should be doing to see how we trend in various areas.

Q: What changes needed to take place in order to accommodate the extra work put toward benchmarking?

DW: We have a staff member dedicated to completing the quarterly ASCA quality survey. I also have a business office manager that completes data and other national and local surveys related to cost, such as the MGMA survey which comes out once a year. Along the way, we benchmark with local organizations such as the local human resources organization and the American Society of Gastroenterologists.

Learn more about Menomonee Falls Ambulatory Surgery Center.

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