QAPI Studies: Finding New Ideas

Ep. 102: Becky Zeigler-Otis – QAPI Studies: Finding New Ideas

Here’s what to expect on this week’s episode. 🎙️

Struggling to find new QAPI study ideas for your ASC?

In our latest podcast, Becky Ziegler-Otis from the ASC Quality Collaboration, shares how to keep your quality improvement efforts fresh and how to generate new ideas.

✅ Benchmarking is Key: Use both internal (your own historical data) and external (industry benchmarks) to identify performance gaps.

✅ Look Within Your ASC: Your risk management reports, infection surveillance data, medical record audits, and even patient, employee, and physician surveys are goldmines for QAPI ideas. Pay attention to recurring comments in surveys—they often highlight hidden issues.

✅ Revisit Past Studies: An old study from years ago might uncover new issues due to changes like staff turnover, new procedures, or post-COVID shifts. Continuous improvement isn’t just about new ideas—it’s about re-evaluating old ones, too.

✅ Tap into Free Resources: Participate in the ASC Quality Collaboration’s free Safety & Quality Assessment (Feb 1–Mar 15, 2025). You’ll get personalized benchmarking reports to identify strengths and areas for improvement.

QAPI doesn’t have to feel overwhelming. Start with data you already have, stay curious, and keep refining your processes!

Episode Transcript

[00:00:00] Welcome to this week in Surgery Centers. If you are in the ASC industry, then you are in the right place every week. We’ll start the episode off by sharing an interesting conversation we had with our featured guest, and then we’ll close the episode by recapping the latest news impacting surgery centers.

We’re excited to share with you what we have, so let’s get started and see what the industry’s been up to.

Erica: Hi, everyone. Here’s what you can expect on today’s episode. We are kicking off a new three part series today all about QWAPI studies. Joining us today is Becky Ziegler Otis, who will share practical tips for generating new study ideas. The following week on February 18th, Tina DeMarino will give us an inside look into what surveyors are looking for.

Erica: And finally, on February 25th, Kathy Wilson will walk us through the 10 step process she used to run a successful study that reduced case cancellations at a [00:01:00] GI center. But looking more closely at this week’s discussion, Becky is the Assistant Executive Director at the ASC Quality Collaboration, alongside being an active ASC consultant and member of the ASCA Education Committee.

Erica: Having ran an ASC for many years herself, Becky is no stranger to QAPI studies, and today she shares how to find new ideas through internal and external benchmarking. In our news recap, we’ll cover consolidations in 2025, the new ASC safety and quality assessment, laws, and of course, end the news segment with a positive story about a nurse who went above and beyond during the LA wildfires.

Erica: Hope everyone enjoys the episode and here’s what’s going on this week in surgery centers.

Erica: Hi, Becky. Welcome back to the podcast. Hi, Erica. How are you today? I’m great. Thanks so much for joining us. Can you please tell our listeners a little bit about yourself [00:02:00] and your ASC experience?

Becky: Sure. So my name is Becky Zaglaronis, and I’ve been involved in the ASC industry for about 15 years.

Becky: And the majority of that time I spent as the administrator of an independent multi specialty surgical center that’s located in central Wisconsin. And as the administrator, like probably a lot of you listening to this podcast, I was the person responsible for QAPI. So I so understand what you’re going through as it relates to looking for QAPI studies.

Becky: So currently, Erica, I’m actually working as the Assistant Executive Director of the ASC Quality Collaboration. And we often refer to ourselves as the ASCQC, and for those who are listening, if you’ve never looked at the resources that we can provide you as independent ASCs, I’d encourage you to go out to our website, ASCQuality.

Becky: org, because you will find a tremendous amount of resources as it relates to ASCs. To benchmarking toolkits, and that would be really helpful for you within your organizations. [00:03:00]

Erica: Love it. Yeah. The free data that your organization provides is unbelievable. I look at it all the time when we do our report, our state of the industry report, I’m always looking at the data that you guys offer as well.

Erica: So you really do provide a wonderful service to the industry. And that is exactly why I wanted to have you on today to kick off our three part co op series. So please. Set the scene for us a little bit with QAPI studies in general. Why do ASCs have to do them and how often?

Becky: Right. So I think QAPI studies are, that’s really continuous improvement.

Becky: And when we think of our organizations and where we want to go in the future, we’re always looking for What can we improve upon? How can we move that needle forward? How can we achieve excellence? Because that’s what we do in surgery centers. We provide excellent patient care. And so that’s really what QAPI in my mind is all about.

Becky: And I think about [00:04:00] As my day in my day to day life as an administrator, there wasn’t a day that didn’t go by where I didn’t have people standing outside my door with issues or concerns or problems. And sometimes it was a line, as I know many of and those issues or concerns were important to hear because Really, they become subject matters, topics, things that we can look at for performance improvement.

Becky: But aside from that, it’s also required as part of our accreditation or certification, Erica. So for example, if, and I’m just going to use CMS certification because everybody has to have that or they move into an accreditation organization. But when you think about the CMS standards and the standard that I know is out there is called CMS standard 416.

Becky: 0. 43. If you want to look at it yourself, and that one totally relates to performance improvement. And what it requires is that surgery centers, actually, if you read that standard, it’s going to say the number and scope of distinct improvement projects conducted annually. [00:05:00] have to reflect the scope and complexity of the ASC.

Becky: So why do we do them and why are they important? It’s because of that. They required of us, we need to do it at least annually. And also in addition to that, they also require that if you’re a larger ASC, you need to actually do more improvement projects to reflect the scope of services.

Becky: So depending on, your, accreditation organization that you participate with, they can have standards that are above and beyond what’s required for CMS. So minimally meeting the CMS standards, and then if you are accredited, looking in what those standards are for those various accreditation organizations.

Becky: And that’s why it’s important as well.

Erica: Sure. Definitely. And one thing that I’ve learned just, going through the process of preparing for this series and just in general was the role that benchmarking plays. I didn’t realize, how important benchmarking was. Cause you think like, oh, we’re just gonna, improve [00:06:00] something internally, but tell us more about the role that benchmarking does play.

Erica: Cause it’s super important.

Becky: It is important. And I think benchmarking is pivotal to performance improvement in QAPI studies. And actually, when I first started as an administrator, I always thought that benchmarking was really external, that I had to look for external opportunities. And what I think, what I really want to make sure that the listeners hear is that there’s a value in both internal and external benchmarking.

Becky: So internal benchmarking really looks at how we’ve done in the past. How we’re performing now and what we can do in the future to get it better. And sometimes there are measures that we’re looking at that actually we were doing better in the past and using that past benchmark internally looking at that, how to push ourselves forward to maybe where we were in the past.

Becky: So I think that’s very valuable. And then external benchmarking is where you’re looking outside of your organization. So it’s not inward facing like internal benchmarking is, it’s [00:07:00] outside your organization. So you want to look for organize a other surgery centers, whether it be within your region, within your state across the country, where you look at how they’re performing and compare yourself.

Becky: And between the two of those, you then are able to identify your QAPI studies. And when you think about benchmarking, really it is pivotal to performance improvement or QAPI because think about what it is. Benchmarking is really finding a measure. Finding a measure after you have that measure you have to track that measure and then when you track the results of that measure You can analyze it.

Becky: Once you’ve analyzed it That’s when you can set your goals or your targets and those goals or targets can be internal targets You can use external resources if you have them and then it evolves into a QAPI project If you’re not meeting the target or the goal that you’ve established for yourself So I think Benchmarking is part and parcel of what we select for our QAPI [00:08:00] studies.

Erica: That makes a ton of sense. And the million dollar question why we’re here today to talk about how to find those new ideas. So you’ve already given us some great examples, in your staff, right? People standing outside your door internal, external, but tell us, let’s go a little deeper.

Erica: What are some common sources of inspiration for a QAPI studies?

Becky: Yeah, that and that is the million dollar question because a lot of times we sit as an administrator at the end of the year, the beginning of the year. And what is it that we want to study? So I would like to provide everyone with just some resources that you have all within your surgery centers that you can tap into to look at what you might want to study.

Becky: So, for example, I’ll go through a couple of them for you. We all have to have a risk management program. So in our risk management program, we are tracking. Sometimes they cause harm, sometimes they don’t, but we’re tracking those events. And so some of those events are things like [00:09:00] burns or falls, unplanned transfers.

Becky: And when they happen, We have an occurrence report. We look for opportunities for improvement. Sometimes we do a root cause analysis if it desires that. But your occurrence reports, taking a look at the trending in the past on how you’ve performed on those different measures. If you’ve had some events can lend itself to ideas for performance improvement.

Becky: I also think of your infection surveillance that has to be done by all surgery centers as well. And so we’re looking for whether or not we’ve had some surgical site infections within 30 days following the procedure. And we’re also tracking complications and we might do it in different ways, but we all have to do it.

Becky: And so taking a look at those resources, how have you been doing with surgical site infections, or maybe. You started a new procedure and you’ve noticed that you’ve got a complication that’s occurring related to that procedure. So there is an idea for a study. So take a look at that. [00:10:00] Another resource I think about is CMS’s resource that they use for when they come on site and they do their infection control review.

Becky: It’s called the infection control worksheet. It’s an extensive document, but it’s one that if you take a look at it and maybe review that on an annual basis, quarterly basis, whatever it works for your center, take a look at how you respond to some of those questions because those can provide some insights into ideas.

Becky: For example, there’s a whole section on hand hygiene and it seems like no matter how hard we try, hand hygiene still keeps coming up as something we can look at. So let’s say when you’re doing that evaluation or using that survey tool, it shows that maybe each time someone takes off their gloves, they’re not Appropriately doing handwashing, not each time, that is an opportunity for improvement.

Becky: Well, maybe just taking that as a portion of what you want to study. But I just pull that out as one question. But take a look at that worksheet because as I said, it’s filled with questions and depending upon how you answer those [00:11:00] questions, you could have some opportunities for improvement. I also think about the ASC quality reporting program that we participate in.

Becky: If we participate in with Medicare the mandatory measures that we track so that we can get that market to market basket update. And some of those measures are your burns, your falls. There’s also normal thermia, things of that nature. So take a look at that. Reflect, take a look, see where you’re performing and do you want to do something better related to that?

Becky: So you’ve got that. I think of another resource is your medical record audits or your reports. So for example, we’re probably all reviewing medical records on a periodic basis, looking for some opportunities for improvement. And so maybe in your regular review of records, and I just throw this out as an example, that you have a pattern that when someone experiences pain, you provide some pain management [00:12:00] intervention.

Becky: But you find that you regularly see in your records that maybe after the intervention has taken place we forget to go back and measure that pain score. So maybe that is something to take a look at definitely impacts our patients. So it’s whatever you’re looking at. Maybe you’re looking at cancellations.

Becky: Cancellations are important to look at because they definitely impact a number of things within our surgery centers. And so maybe you’re tracking your cancellation rate and you’re finding that you have a pattern related to, you’ve got add ons that are coming in at the last minute and you’re not able to do your proper prior authorizations and therefore having to cancel.

Becky: I’m just using that as an example. But looking at that, on a regular basis. And then I also think about the surveys. So, we all do a number of surveys, whether it be an employee satisfaction survey, physician satisfaction survey, and now we have OAS CAHPS, if you’re participating in that. And so, you [00:13:00] have those survey questions, and depending upon how you score on those questions, can provide for a tremendous amount of ideas in which to look at for QAPI.

Becky: I also think if you’re not participating in a patient safety culture survey by that might be an opportunity for you to reach out, look at the AHRQ website. They have a survey that you can participate in, and once again, a wealth of information. When I think about surveys, I also think about comments, and what resonates with me is many times on our patient satisfaction surveys, it wasn’t necessarily the questions.

Becky: But it was the comments. So maybe you have a comment, for example, that’s a regular comment that says, geez, it took a while for them to start my eye. And that may force you to say, maybe I want to take a look at what’s the average number of IV starts that we have before it, it works appropriately for us.

Becky: And that could be an [00:14:00] opportunity for education of staff or all sorts of things. And so hopefully That’s enough things that I’ve really sparked some creativity that maybe think about some of the things that you’re already collecting that you can use for internal benchmarking to push yourself forward for a QAPI study for next year.

Erica: Yeah, that is. Those are amazing. You just rattled off so many sources of inspiration. But the surveys is interesting because I always obviously think about patient surveys, but I forget about the employee surveys of physician surveys. And that could just be a completely untapped market that people haven’t even considered looking at.

Erica: Let me ask you a question. Do you ever find I’m thinking about the admin who’s been an admin for, 15 years at the same facility. Do you ever find that they’ll go back to a study they did maybe seven or eight years ago to redo it? Not in the sense of [00:15:00] like, it’s just easy to redo something, the foundation is already there, but in the sense of Continuing to try to improve that number.

Becky: Oh, Erica, actually, that is another great source. So I’m glad you brought that up. There are many times that maybe you did a project several years ago. Maybe you looked at cancellation several years ago and you really didn’t have a problem, but things have changed. We’ve gone through COVID we’ve had staff turnover.

Becky: We’ve had physician turnover. We’ve had to take on different types of procedures to actually be more. financially viable. And so sometimes those things that we did as a study and we were doing well, and that’s why we concluded the study can actually be some potential opportunities that now that things have changed, we may need to go back and take a look at that again.

Becky: So that too is another great way to look at performance improvement studies.

Erica: Sure. Interesting. Okay, let’s talk about external [00:16:00] benchmarking. I know we talked about it a little bit, but I feel like people can sometimes feel stuck in where to turn when it comes to that, or maybe they’re just familiar with ASCA or just familiar with ASCQC.

Erica: Where else can they look to find those metrics?

Becky: There’s plenty of sources, but I, I confess that when I was Working in my role as the administrator, I struggled. I tried to read as many publications as I could and stay as educated as I could. However, I know I missed some wonderful external benchmarking resources.

Becky: So hopefully I can help some of you listening that you don’t have to have the same struggle that I had. So the first thing I think about is state associations. Now, this really depends upon what state you’re in, but there are some states that actually are Having, they have some benchmarking programs that you can participate in.

Becky: For example, California, Florida, Colorado. So check with your state association. I know there’s only a handful out there, but if you happen to be within one of those states, why [00:17:00] not tap into that resource? It may be a pay to participate. You’d have to check that out, but that can provide a wealth of information if you happen to be in one of those states.

Becky: The other other external benchmarking resource, I think of right off the top of my head is ASCA. ASCA provides a clinical and operational benchmarking program survey that you can participate in. It’s a great program. If you’re not participating in it, maybe check it out. And the reason that I think it’s great is it has a number of content areas that you can participate in.

Becky: Submitting your data and then getting data back. So it goes through volume, quality, operational outcomes, complications, staffing, financial. So it’s a number of areas and they also have some specialty reporting such as total joints, complex spine and ophthalmology. So they offer that as well. The beauty of ASCA’s reporting program, once you participate, is when you get your center specific [00:18:00] report back, you can trend your results over time and then you’re comparing it.

Becky: And they have a lot of different ways to compare it within your region, nationally. So they have different ways of comparing it. So, I think that’s a really great point. I offer that as an option that is a pay to participate, but the fee you’d have to look out on their website. It’s not all that expensive to participate in.

Becky: So that’s another resource. And then I think about, of course, in my role in the ASC quality collaboration, I have to talk about that resource. So, the ASC quality collaboration has a wealth of benchmarking information on their site that is related to. clinical benchmarks. And so those clinical benchmarks are aligned with the ASC quality reporting for Medicare.

Becky: So you’ll see the same measures, that they have, as well as maybe a couple additional measures. But what’s great about that resource is, well, first of all, it’s free. You go out to the website, you can see the average performance on various [00:19:00] metrics. It’s updated. It’s updated all the time. So in other words, first quarter data that people have gathered will be put out there by the end of the second quarter.

Becky: So it’s very relevant information. And when you look at the depth, the number of admissions it represents, it’s phenomenal. And so I encourage you to look at that as a resource. In addition, then there’s some toolkits that go along with it. So let’s say you’re tracking a metric on balls and you’re not quite sure what to do to improve your results with balls, that they also have toolkits that can help you with that.

Becky: And then also just because of timing of this is right now, I want to mention that. between February 1st and March 15th. There’s an open submission period if you want to participate in the ASC patient safety and quality assessment program. And so by submitting I encourage you to go out on the website.

Becky: I won’t take the time to talk about it now, but what it will provide you with if you [00:20:00] participate in this is a center specific report and an aggregate report of those who submit their information on various. processes related to safe quality practices. And that will be able to provide you with some depth of information for benchmarking as well.

Becky: So, so enough about the ASC quality collaboration. I’ll include

Erica: links to all that in the episode notes too, because. There you go, right? People are really looking to find ideas. They can participate in this assessment you guys are offering. It’s free. Why not? And then, they get so much data to, inspire QAPI studies and also just, who doesn’t like data about themselves?

Erica: So. Correct. Correct.

Becky: Yeah. But I can offer a couple other resources as well Erica. So I think about your accreditation organizations. So there’s four right now accreditation organizations for ASCs. And so if, depending on who you’re accredited for, you could reach out to your organization. But I also know [00:21:00] that the Triple HC offers some benchmarking studies.

Becky: Again, it’s a pay to participate. And you do not have to be accredited by them to participate in their benchmarking studies. And I checked out on their website before I talked with you today, Erica. And between January and June of this year, you can participate in studies related to hand hygiene allergy documentation, colonoscopy practices, and medication reconciliation.

Becky: So that might be something to consider again, you have to pay to participate. There’s also some specialty societies. So if you’re an ophthalmology center, you’re probably aware of your specialty society that does some data gathering and the same with GI. So I’d encourage you to check those resources. And then finally, don’t forget about the resources we may not think about.

Becky: So for example, HST, which I’m talking with Erica today has their state of the industry report. So look for opportunities like that, that are out there because if you haven’t read that state of the industry report, I’d encourage you [00:22:00] to do that. It has a wealth of information that actually you can take many of much of the information that’s in there and turn that into a quality study.

Becky: If there’s something important. in there related to your organization. I think of the wealth of data that’s out there for example, on cancellations. It’s wonderful information. So look for other avenues that you can tap into as well. So those are my thoughts as far as external benchmarking.

Erica: That’s awesome.

Erica: And again, I mentioned this earlier, but I’ll include links in the episode notes to everything you just mentioned so that it could be super easy for everyone. To build their word doc, wherever you store this type of stuff to, when the time is needed, you got to get that, the inspiration doc ready.

Erica: So you can access it whenever you want. All right, Becky, last question. We do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers?

Becky: What I would say is one thing you can [00:23:00] do is try to carve out time this week. And the reason I say carve out is because I know as an administrator your week is already So I’m saying if you can try to just carve out maybe an hour of time, might be a lot of time to commit to this, to just do some rounds, go around, talk with your staff, talk with your surgeons, talk with your patients.

Becky: And with the question saying, is there anything you think we can improve upon? Because I think if you did that, you would also have a plethora of information that could help you as you’re looking forward to what you need to do for your QAPI studies for the next year.

Erica: Love it. That is great advice.

Erica: Thank you so much for coming on today, Becky. We really appreciate it.

Becky: No, thank you, Erica, for having me. Thank you, HST, for allowing me to participate in this podcast.

Erica: As always, it has been a busy week in healthcare, so let’s jump right in. ASCs are seeing a big wave [00:24:00] of consolidation, and it’s only expected to grow in the coming year. Both PE firms and health systems are diving deeper into the outpatient surgical space, bringing new opportunities, but also new challenges for independent centers.

Erica: Todd Currier from Bend Surgery Center points out that smaller physician owned ASCs have thrived because they’re agile, cost efficient, and personal. His advice? Be cautious with consolidation. We’re small businesses, not health systems, he says, and our agility is what built this industry. But not everyone sees consolidation that way.

Erica: The VP of Business Development from Merit Healthcare argues that it can be a strategic move offering benefits like admin support, staffing solutions and better negotiating power with payers if managed correctly and carefully. Joint ventures with health systems are also gaining traction offering referral networks and help with staffing shortages but a reminder that there’s always a catch.

Erica: Too much hospital bureaucracy [00:25:00] can bog down in ASC’s efficiency. So what’s the takeaway here? Consolidation is definitely here to stay, but centers that stay proactive, so aligning goals involving physicians and staying engaged with these groups, can still thrive while keeping their core strengths intact.

Erica: All right. Switching gears. The ASC quality collaboration has officially released their ASC safety and quality assessment. Now, if you listen to our guest discussion earlier on the episode, then you know all about the assessment as Becky Ziegler Otis mentioned this while we were chatting about finding new QAPI ideas, but here’s some more info on what you need to know.

Erica: This assessment is a great opportunity for surgery centers to benchmark their performance against their peers. So it’s a free online survey that’s open to any Medicare certified ASC, and the submission window runs from February 1st to March 15th, 2025. Assuming you’ve gathered all the necessary [00:26:00] information ahead of time, it only takes about 20 minutes to complete.

Erica: The assessment covers key areas like patient safety, infection control, medication management, governance, and patient experience. And once the submission period closes, participants will receive a personalized report with both their individual results and aggregated data from ASCs nationwide. It’s a powerful tool for showcasing your center’s quality to patients, payers, and prospective physicians, while also identifying areas for improvement.

Erica: Now, we are always talking about the importance of benchmarking here, both internally and externally, but it could be really hard to find reliable, relevant kind of apples to apples data. And ASCs though, who are committed to proving their value with data driven insights will be the ones who experience long term success.

Erica: And as more centers participate in things like this, the industry strengthens its position as the preferred site for outpatient procedures. I will put a link to the assessment in the [00:27:00] episode notes as always, and I hope you all take advantage of this awesome opportunity.

Erica: Again, it closes March 15th, so make sure you get in there. All right, third story. Colonoscopy requirements are on the decline and it’s creating real challenges for both physicians and patients. To give you some context, from 2007 to 2022, reimbursements for GI procedures dropped 7 percent unadjusted and a whopping 33 percent when adjusted.

Erica: Colonoscopy and biopsy payments alone fell by 38%. Meanwhile, demand is rising, with the recommended screening age now lowered from 50 to 45, and Medicare expanding coverage accordingly. But even with broader coverage, financial barriers remain. Only 17 percent of patients pay nothing for bowel prep, and many are steered towards cheaper, non FDA approved options.

Erica: Plus, if a screening colonoscopy becomes diagnostic, [00:28:00] patients can face up to 15 percent coinsurance, especially at an ASC. So to tackle these issues, several states are coming up with new ideas and stepping up to the plate. So California, Illinois, Kentucky, Nebraska, and Vermont have passed laws expanding insurance coverage for colonoscopies from covering bowel prep and anesthesia to eliminating cost sharing entirely.

Erica: So what does this mean for us? It’s really a mixed bag while declining reimbursements, strain margins, state level reform show momentum towards better coverage. So as always, stay informed, talk to your state associations, talk to ASCA so you can adapt to these changes and be better positioned to maintain access and manage costs.

Erica: And to end our new segment on a positive note, when wildfires swept through LA County, one nurse stood out for her extraordinary dedication, Shamika Osi, who has been recognized as the nurse of the week. [00:29:00] As an emergency preparedness public health nurse since 2012, Shamika’s leadership was vital during the crisis.

Erica: Shemeika started at a FEMA disaster recovery center in West LA, helping displaced residents reconnect with life saving medications. Whether transferring prescriptions or arranging telehealth appointments, she was a steady hand during the chaos. And beyond the recovery center, she attended community meetings, offering critical health info, resources, and even respirators to fire victims. Shemeika also led operations at the Malibu Pacific Palisades repopulation checkpoint, ensuring both public and team safety in tough conditions.

Erica: And despite facing personal challenges, her own son was hospitalized due to wildfire related air quality. She did remain committed to her work. So Shamika’s resilience, compassion, and leadership are what make her such an inspiration. She’s a great reminder of the critical role that nurses play, not just in the hospital, but on [00:30:00] the front lines of disaster response as well.

Erica: And that officially wraps up this week’s podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you’re listening from. I hope you have a great day and we will see you again next week.