Quality Improvement Study:Endoscopy Template for Improved Reported Rates of Compliance
Purpose of Study
What can our surgical center do better in regard to reported rates for ASC–9 and/or ASC–10?
· ASC–9: Are physicians consistently recommending and documenting follow-up interval of at least10 years for normal colonoscopy on average risk patients? YES NO
· ASC–10: Are patients who have a history of colonic polyps receiving a colonoscopy in an interval that is 3 years with supporting documentation? YES NO
Goals and Objectives
· Improve compliance with ASC-9 recommended follow up of at least 10 years
by ____ percent.
· Improve compliance with ASC-10 recommendation of interval 3 years for surveillance colonoscopy with previous colonic polyp by ____ percent.
Data Collection
Initial patient population is defined by the ICD–10 and current procedural terminology (CPT) codes for patients who have had a colonoscopy.
ASC–9: Identify patients who are of average risk and have a normal colonoscopy.
Compliance with this measure is indicated by physician recommendation for a follow-up interval of at least 10 years.
ASC–10: Identify patients who have a history of colonic polyp(s).
Compliance with this measure is indicated by the interval from last colonoscopy of 3 years.
To ensure the population is determined accurately, utilize the fact sheets for ASC–9 and ASC–10 as well as the template for collecting ASC-9 and ASC-10 found in the HSAG toolbox.
Step 1. Review and compare the data you have—This includes previously reported ASC–9 and ASC–10 data, as well as any concurrent data (current year) you have collected.
Reference measure reports provided by HSAG and use the Data Tracker spreadsheet provided in the Health Services Advisory Group (HSAG) toolbox.
Ask: Is facility ASC–9 performance: BETTER WORSE NO CHANGE
Is facility ASC–10 performance: BETTER WORSE NO CHANGE
Step 2. Compare the findings of your data review against your Quality Improvement Goal.
ASC–9 Current Data: ______Quality Improvement (QI) Goal: ______
ASC–10 Current Data: ______Quality Improvement (QI) Goal: ______
Step 3. Examine the process(es) that impact this outcome and collect data on how often things are done right, and how often they are not.
Use chart review, Assessment and Documentation process observation, Staff feedback etc.
Data Analysis
Barriers we need to address in order to meet our goal:
1.______
2.______
3.______
Change Process:
Strategies we will implement in order to meet our goal:
1. ______
2. ______
3. ______
Performance Comparison:
· Determine the measurement timeframe. For example, if strategies are implemented before July 1, 2017, allow for one full quarter of data to be collected and then compared against Q1 through Q2 of 2017 (January 1–June 30).
· Report and document findings in Quality meeting minutes.
· Present all findings to your Medical Executive Committee and Governing Body on your regular reporting schedule.
· Share your findings with your team, encourage feedback, and look for continued opportunities for improvement and sustainability of results.
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-D.1-03242017-01
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