Ambulatory Care Quarterly: Ambulatory programs call for different type of CQI
Schedule, patients who leave add to challenge
One more chore. One more piece of paper to complete. One more thing that pulls nurses away from patient care. One more way for managers to find fault with staff members. One more thing that you have to do for accreditation. Well, it is required for accreditation, but a continuous quality improvement (CQI) program doesn’t have to be the arduous busy work or the negative task that some staff members think it is.
"For a CQI program to be really effective, it has to be meaningful to staff members," says Sheryl Walker, MD, medical director of The SurgiCenter of Baltimore in Owings Mill, MD. "CQI activities should never be punitive, and they should always present an opportunity for staff members to suggest ways to improve."
The most important reason for an ambulatory surgery program to have a CQI process is to improve itself, Walker says. "None of us can get better if we don’t have a way to identify the areas where improvement is needed," she explains.
The second reason is accreditation, Walker says. But even if an ambulatory surgery program is not undergoing an accreditation process, the self-improvement is reason enough for CQI, she says.
QI in ambulatory surgery is different from CQI in an inpatient surgery program, Walker says. "We have a different patient population, a different caseload, different techniques, and most importantly, our patients go home after the procedure," she explains.
These differences mean that measuring different aspects of the patient’s recovery such as pain management or infection is difficult, but there are several other areas that are important and easier for ambulatory surgery programs to monitor, Walker adds.
"Everyone should monitor complication rates," Walker says. Death, transfers to a hospital or intensive care unit, and returns to the operating room (OR) from the post-anesthesia care unit are critical to document and evaluate, she states. "Your anesthesia service should also be tracking any dental or eye damage as well as untoward neurological aftereffects," Walker adds.
Use your time efficiently
Time management is another key area for ambulatory surgery programs, she says. "It is important for us to start cases on time, turn over rooms quickly, and reduce lengths of stay in recovery," she explains. "The efficient use of time impacts staff morale, financial success, and the program’s ability to keep surgeons on staff."
The areas on which you focus your CQI efforts depend on your program, she states. "All same-day surgery programs are not equal," Walker says. A program that performs predominantly gynecological procedures probably will not focus on dental damage during anesthesia, just as an eye surgery center will not focus on problems that are related to general anesthesia, she says.
The key to making a CQI program accepted and welcomed by all staff members is to keep the measurement tools simple so staff members don’t feel that they are spending more time on paperwork for quality measurement than they spend on quality patient care, Walker emphasizes.
Simple is a good way to describe the Nursing Concern Form used in the ambulatory surgery program at Fairfax Hospital in McLean, VA. A place for the date, the topic, and the name of person to whom the form is submitted is at the top of the 8½ by 11-inch form that is mostly composed of blank lines on which the staff member can write. The person submitting the form signs at the bottom, then there is a small space to describe the action taken.
"We used to have risk management forms that OR nurses would complete if they encountered something like a room that wasn’t properly cleaned," says Paula R. Graling, RN, MSN, CNOR, clinical specialist at Fairfax Hospital.
Putting concerns in writing
Because these forms are used as a formal method of collecting data for risk management and quality improvement, they had to travel through different department supervisors and often resulted in up to a three-week delay in solving problems, Graling says. Now, if the problem is not a unitwide or consistent problem, the Nursing Concern Form is used.
"The Nursing Concern Form is used within our own department," Graling says. "It can go directly to the person overseeing housekeepers in the OR for the example of the improperly cleaned room, or directly to the chairman of the surgery department if the concern is a chronically late surgeon," she says.
"The form is not used to collect data; it is used to solve problems," explains Graling. The person submitting the form is supposed to state the concern very specifically and whenever possible, suggest ideas to correct it, she says.
"These forms make it easy for people to communicate directly with each other and find solutions that meet everyone’s needs," Graling explains.
Although clinical managers review the completed forms, after solutions are reached, they do not get involved unless there are problems reaching a solution or the solution requires a manager’s authorization. Review of the forms gives the managers an overview of what is happening in the fast-paced same-day surgery program, adds Graling. This overview can lead to suggestions of activities that CQI might want to monitor in a more formal manner.
When you monitor different activities, it is often difficult to find benchmarks that apply specifically to same-day surgery, says Nell Wood, director of marketing and communications for the Quality Indicator Project at the Elkridge-based Association of Maryland Hospitals & Health Systems (MHA).
This project collects data from participants across the country and builds a database of national data. The fee ranges from $1,390 to $3,800 per year.
While the majority of measurements are related more to acute care, there are some categories that address same-day surgery interests, Wood says.
Admission to an inpatient unit for observation following same-day surgery or diagnostic endoscopy, cancellation of procedure on the day of surgery, and type of sedation or analgesia used for endoscopic procedures are examples of categories related to outpatient, she explains.
The Accreditation Association for Ambulatory Health Care’s Institute for Quality Improvement in Wilmette, IL, offers a variety of benchmark studies that can provide information for CQI programs, says Naomi Kuznets, PhD, managing director of the institute. (See contact information at the end of this article for more information.) Studies cover areas such as tumescent liposuction, patient satisfaction, and cataract extraction.
Whether you choose to incorporate national benchmarks into your CQI program or not, Walker says, "A CQI program can be most meaningful when everyone views it as a learning process that will improve the work environment and patient care."
[For more information about CQI in ambulatory surgery programs, contact:
- Sheryl Walker, MD, Medical Director, The SurgiCenter of Baltimore, 23 Crossroad Drive, Suite 100, Owings Mill, MD 21117. Telephone: (410) 356-0300. Fax: (410) 356-0309.
- Paula R. Graling, RN, MSN, CNOR, Clinical Specialist, Fairfax Hospital, 1606 Fielding Lewis Way, McLean, VA 22101. Telephone: (703) 698-2387. Fax: (703) 442-0198. E-mail: [email protected].
For more information about the QI Project of the Association of Maryland Hospitals and Health Systems, contact:
- MHA: The Association of Maryland Hospitals & Health Systems, Quality Indicator Project, 6820 Deerpath Road, Elkridge, MD 21075-6234. Telephone: (410) 379-6200. Fax: (410) 379-9551. E-mail: [email protected].
For more information about studies produced by the Accreditation Association for Ambulatory Health Care’s Institute for Quality Improvement, contact:
- Accreditation Association for Ambulatory Health Care, Institute for Quality Improvement, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091. Telephone: (847) 853-6079. Fax: (847) 853-9028. Web site: www.aaahc.org.]
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