Page 14 - 2020 ARE eGuide for Clinical at Nonhospital Sites

Ambulatory Surgery Centers Snapshot

Quality Overview
If you work in the outpatient area, it is important that you review these quality measures. These
CMS and evidence-based actions focus on timeliness and effectiveness of care based on select
patient conditions. Successful performance depends on how well staff assess patients, follow
through with orders, and/or notify medical providers if there are missing care interventions –
followed by appropriate and timely documentation.

QUALITY Benchmark
CMS Required Quality Metrics Wrong Site, Wrong Patient, Wrong Procedure Implant (ASC-3) (proposed removal Sample size 96
Patient Burns (ASC-1) (proposed removal CY-2021)
0%
Patient Falls (ASC-2) (proposed removal CY-2021)
0%
0%
CY-2021)
< 1.3%
Hospital Transfer / Admissions (ASC-4) (proposed removal CY-2021)
Flu Vaccine (Center Employees & Physicians Combined) (ASC-8)
80%
Endoscopy/Polyp Surveillance: Appropriate follow up≥- Average Risk (ASC-9)
per year
Safe Surgery checklist
Yes
≥97%
Normothermia (ASC-13)
≤ 2%
≥30%
Adenoma Detection Rate - Male
American Society for Gastrointestinal Endoscopy Vitrectomy Rate (ASC-14) ≥6 min
Adenoma Detection Rate - Female
≥20%
≥20%
Adenoma Detection Rate - Total
≥95%
Cecal Intubation Rate
Withdrawal Time (minutes)
Best Practice Metrics H&P Compliance 100%
0%
Surgical Site / Post Procedure Infection Rate
Physician Response Rate (% of MDs that notify the center of any infections
≥90%
/complications)
Pathology Physician Verification
≥75%
≥70%
On Time First Start
>90%
Hand Hygiene