QAPI Studies: What Surveyors Are Looking For

Ep. 103: Tina DiMarino – QAPI Studies: What Surveyors Are Looking For

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

When a surveyor is reviewing your QAPI studies, what are they actually looking for?

Tina DiMarino is the CEO of Custom Surgical Consultants and also an AAAHC Surveyor. On this week’s episode of This Week in Surgery Centers, Tina joins us to talk through what surveyors are looking for. Here’s a cheat sheet.

➡️ Meaningful Impact: Surveyors want to see that your study addresses real issues in your ASC—not just a routine checkbox exercise.

➡️ Quantifiable Goals: Studies must have measurable benchmarks and clear corrective actions. Saying “we improved” isn’t enough – data should prove it.

➡️ Sustainable Change: Fixing a problem once isn’t the goal. Surveyors look for long-term improvements and follow-up evaluations to ensure changes stick.

➡️ Common Pitfalls: Vague goals that aren’t tied to data, overcomplicating studies with excessive details, and repeating ineffective studies.

#ASC #QualityImprovement #QAPI

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 going to be continuing our three part series all about QAPI studies. Last week, we heard from Becky Ziegler Otis, who shared some amazing insights into how you can generate new ideas for your studies. And today I had a chance to talk with Tina DeMarino.

Erica: Tina is the CEO of Custom Surgical Consultants, a board member of the Maryland ASC Association, and an AAAHC surveyor. So Tina’s going to give us the inside scoop of what [00:01:00] specific aspects of QAPI studies surveyors typically focus on during an inspection. After my conversation with Tina, we will switch to our data and insights segment.

Erica: HST released our annual state of the industry report this past September, which analyzed client data from 590 surgery centers. So today I’ll share with you the cardiology trends we saw from 2023 to 2024. Specifically around OR duration, revenue per case and revenue per OR minute. Hope everyone enjoys the episode and here’s what’s going on this week in Surgery Centers.

Erica (2): Hi, Tina. Welcome to This Week in Surgery Centers. Hi, thank you for having me, Erica.

Tina: Great to be here.

Erica (2): Yes. Before we get started, can you please share your ASC background with our listeners?

Tina: Absolutely. I’ve been in the ASC C industry for 24 years now mainly all in leadership roles.

Tina: I’m a certified administrator and [00:02:00] certified OR nurse and have my doctorate in nursing practice.

Erica (2): So we just had Becky Ziegler Otis on last week to kick off our three part QAPI studies. And She did a great job of kind of laying the foundation of what co op studies are, why they’re important, how to generate ideas for new studies. And today we’re just going to take a closer look with you at what surveyors are looking for when they do come by.

Erica (2): But first from your experience, what role do co op studies play at a surgery center?

Tina: So they are the very tool that the quality assurance department uses to create improvements within your center. So if you’re having a trouble with any process, anything to do with risk management, safety, infection control, we’ll utilize the quality team will utilize a study to help implement, corrective actions to champion change and bolster.

Tina: Those processes [00:03:00]

Erica (2): got it. And how do CMS requirements differ from accreditation bodies in terms of what is required.

Tina: So CMS really regulates what we need to do to meet those conditions of participation. So they, delineate. Hey, you need to study high prone, high risk areas. They also mandate that the studies need to be quantitative.

Tina: That they need to actually have corrective actions implemented. And the, the reason being is they don’t want, CMS doesn’t want like a one off solution. Oh the nurse made an error, so we fired her. We don’t need to focus in on that anymore. That’s not what they want. They really want you to dive in, figure out, what needs to improve in any of your processes.

Tina: And then they also delineate that they want those changes to be sustainable. So they really regulate [00:04:00] what they want to see in that where an accrediting body certainly wants to see an efficient and an effective quality program. And they have standards for which you know, the ASCs are to meet but they let the ASC delineate more on how they reach those standards.

Tina: So the differences in one’s really regulated while the other is giving you standards from which to work in.

Erica (2): Got it. And do they have requirements in terms of frequency and how often you. Or how many you have to do in a year.

Tina: So I know CMS really wants to see it commensurate with your volume. I know that the very limited benchmark would be at least one a year.

Tina: And then with certain accrediting organizations, you may have to do one or two within your accreditation interval. So we always recommend at the very least that you’re doing at least one study a year.

Erica (2): Got it. Perfect. So from your experience, what specific [00:05:00] aspects of the study are surveyors focusing on during their inspection?

Tina: I think that surveyors really want to see that what you’re working on is meaningful for your organization. I know, and Becky probably went over this, that ASCs have a really hard time figuring out, okay what do we need to study. And so when a surveyor comes in and they read your studies, they want to see first off, is this something meaningful for your center?

Tina: Are you really trying to improve a process? They’re also going to look at, what changes did you implement? And did they work? Did you look at it again to see, six months down the line, was it sustainable? I think from a surveyor’s perspective, they really want to dive in to make sure that, what you’re doing is actually helping your center.

Tina: I know maybe you get challenged with trying to figure out, okay, what do we study? And you do things maybe in a rote manner that really isn’t [00:06:00] improving anything in your center. You’re just going through those motions. So really making it meaningful. Is helpful.

Erica (2): Gotcha. And are there common mistakes or oversights surgery centers make when preparing their QAPI studies?

Tina: I think there are two that we see quite often. So one is not making that performance goal. So what you’re taking from a benchmark, either an external benchmark or an internal benchmark, and you don’t relate your performance goal in a way that is quantitative. Sets your whole study up for not meeting the metrics.

Tina: So you can take a retroactive chart study and find a quantitative percentage performance goal to meet with that. So we see that as something quite often is just taking whatever it is you’re studying and making it quantitative. Another thing that we see is that, the ASC is they want to do a really good job.

Tina: They want to [00:07:00] really nail these studies. Oftentimes it’s a mystery. How are we doing? Why are we doing it? What are, how are we approaching it? And so we see them get lost in all of this data and detail instead of really succinctly just spelling out in a few sentences, what was the problem?

Tina: What did they implement? What were those results and did it make an impact? And so we’ll sit down and there’ll be like an eight pages to a study. And by the time you get on page two, you’re really lost in. What did they work on here? What did they actually implement? So I say one of the things that we see that is challenging is when they try to do too much detail or too much data instead of really focusing on the actual crux of what it is that they’re trying to improve.

Tina: So simpler is better. In, in my opinion.

Erica (2): Yeah, for sure. And that just sparked another question. What is the [00:08:00] format Yeah. that you typically present your your survey results to, to the surveyor or the study results to? Is it a Word doc, PowerPoint, spreadsheet? Do they provide a template? How does, what does that look like?

Tina: I think that Plan, Do, Study, Act, so PDSA is a good format. I think that some accrediting organizations may offer a template or instructions or, six steps or things like that. But really just plan, do, study, act. So focusing in on. What’s your performance goal? What did, what was the problem?

Tina: Why is it important for your center? What are you going to implement? How are you going to remeasure it? So making sure that when you do your study and then remeasure it, you’re comparing apples to apples. I think that any format is is appropriate as long as it’s readable and simple. So you don’t have to go through these elaborate steps and measures to really make a good study.

Tina: It’s just really [00:09:00] focused in answering those simple questions and answering them as succinctly as possible. I think makes it more meaningful and impactful for the surveyor not to get lost in all of the other data or information that you’re providing that may not be necessary.

Erica (2): Yeah, no, that makes a ton of sense.

Erica (2): And you’ve mentioned this a few times, but how can surgery centers ensure that their QAPI studies are both meaningful, which, we obviously want them to be, but also aligned with the surveyor’s expectations.

Tina: Excuse me. So I think really focusing in on I would say start off with benchmarking.

Tina: really comparing yourself if it’s with another colleague with a similar ASC or a peer reviewed journal article really cause we hear it all the time when we go into a center. Oh we do everything great. We really don’t have anything that we need to study. And I think that everyone, [00:10:00] honestly has room for improvement.

Tina: And how to find that information first off would be to really look at external benchmarks. Is your turnover time longer? Are you having any serious near miss events that you need to focus in on? But I think making it meaningful would really be to dive in and find an area where improvement can be obtained.

Tina: So if you’re not, if you’re looking at a benchmark, I’ll be at external or internal. If you’re not meeting that median, there may, if you’re below it there may be an area there, an opportunity for improvement. And I think that certainly garnering members of your team for help with this, because your team if you’re the administrator, they’re in the weeds.

Tina: They see things all the time where they’re like, Oh, we could be doing this better. Or, Oh, I have a friend that said that they do it this way. So really championing that championing or empowering your team [00:11:00] to really get involved. I know we’re all busy administrators are busy. So dividing up that work amongst the team and empowering them to participate is also.

Tina: Really helpful and can make it more meaningful to the center. Because it with empowering them, they, they buy in and then changes become more fun. If, if they’re the ones that, Hey, let’s look at this. And then they realize we can make it better if we do X, Y, and Z, then the buy in amongst them is a hundred percent more than if I come in and say, Hey, I think we need to change this or do that.

Tina: If it’s actually coming from them or. They’re a part of it. You can champion it a lot better.

Erica (2): Yeah. Yeah. I would imagine, if the whole team or an R or a office is all working towards the same goal, then it does almost become fun. How are we doing? You’re all checking in staff meetings, whatever it might be, could be exciting.

Erica (2): Exactly. Yeah. [00:12:00] And

Tina: sorry, go ahead. No, I was just going to say, yeah, it, when you can do that, it really does. I know it sounds whatever, but it can be fun and having everybody on that same mission and vision.

Erica (2): Yeah. Do you ever run into a situation where let’s say the coffee study, easy examples, use case cancellations.

Erica (2): We’re going to try to improve our cancellation rate, in the next 90 days, whatever it might be. Do you ever run into a situation where. It actually didn’t it. The numbers didn’t improve and do. What do you do in that case? It’s a surveyor. Does that look bad to the surveyor or do you just say, Hey, we’re going to continue this for another 90 days and now try X, Y and Z instead.

Tina: That’s a really great question, Erica. And I’m glad that you bring that up because we see it all the time. And I’m just going to change the topic a little bit to say on time starts. This is something that when I was a new nurse and a new administrator [00:13:00] and, docs were coming in late all the time and everybody was complaining.

Tina: I was like I’m going to impact change here. We’re going to do an on time start study. We’re going to make this happen. And I would love you know, do it and we’d get a minimal improvement and then 90 days later we would do it again and get minimal improvement. And it took me a good year before I realized that in certain instances where these surgeons are the owners and they’re going to come in when they’re going to come in, it doesn’t matter what you do or what you’re going to implement, change is not going to happen.

Tina: And so you, therefore you have to live with it. You either change that schedule to meet when the surgeon’s actually going to walk in the door or not study that because you’re really not going to affect change in that regard. To your point on case cancellations that can be seasonal, everybody’s coming down with viruses.

Tina: Now you’re going to have cancellations. There’s really not a whole lot you’re going to be able to do to affect change there. So really knowing [00:14:00] when to stop a study as well. Is paramount because we’ll see going into certain centers who’ve been established and doing things. They’ll do things out of route.

Tina: We’re studying this again because we haven’t met our mark and they’ll keep doing that. And in my mind, that’s like a little bit of wasted man hours because change is not going to be affected. It’s just something that you learn to, this is how it’s going to be. And you try to change things to meet that if you will, and not really that you’re going to.

Tina: bolster up the score to meet something, a metric that you put out there.

Erica (2): Yeah. And I think at the end of the day, they did, you did learn something. There’s nothing we can do about, this on time start issue. And yeah, so we’re going to, try to negate it in other ways. I think that’s, there’s a lesson in there, there somewhere as well.

Tina: Yeah. It took me a while to learn that one, but then I finally got the hang of that. Yeah. But that wasn’t coming in any early, no matter what I said.

Erica (2): Yeah.

Tina: Yeah.

Erica (2): I’m sure [00:15:00] there’s a lot of people listening who can definitely relate to that. Yeah. For sure. All right. Final question, Tina. We do this every week with our guests.

Erica (2): What is one thing our listeners can do this week to improve their surgery centers?

Tina: I think and do you, are you asking that in relation to quality studies? It could be, if so, I thought about it or unrelated. Oh, okay. Yeah. I think empowering team participation. I think that as administrators and with.

Tina: As busy as everything seems to be these days with staffing and, surgeries picking up and things like that, really considering empowering your team and delegating out things evenly along the way. It does twofold. It helps your administrator not be so overburdened as to doing all of it.

Tina: on his or her own, but it also empowers the team to buy in more. So really targeting the team to help with different things that [00:16:00] interest them, infection control or quality or risk or safety. So I really think empowering the team to participate will really help. Your A. S. C. In its improvements and then also help just in an overall teamwork aspect of everything.

Erica (2): Love it. Thank you. That is great advice. Thank you so much for coming on today. We really appreciate it.

Tina: Thank you, Erica. Thanks for having me. It was great talking with you.

Erica: HST Pathways released an updated version of our annual state of the industry report this past September, highlighting best practices, key process steps, and KPIs for every step of the patient journey and for nearly every recurring administrative duty. Most importantly, using our own unique data set from our clients, we were able to extract data points so that anyone in the industry could compare themselves to their peers.

Erica: Two disclaimers, we only pulled data from clients who gave us permission and we [00:17:00] omitted any extreme outliers. So today we’re going to take a look at cardiology trends from 2023 to 2024. If you’ve been paying attention to cardiology and ASCs, you know it’s been a super hot topic, especially with revenue per case being one of the highest among all specialties, second only to ortho.

Erica: But there are some interesting shifts happening that we should break down. So let’s start with three important metrics to know. Between 2023 and 2024, cardiology procedures saw a 20 percent decrease in OR duration, going from an average of 48 minutes per procedure to 34. 7 minutes per procedure. Also from 2023 to 2024, cardiology saw an 8 percent decrease in net revenue per case.

Erica: Now, at first glance, lower revenue per case might seem like a red flag, and it’s definitely not ideal, but here’s where things get interesting. Thanks to those efficiency gains in or [00:18:00] duration, despite revenue per case, dropping the revenue per or minute actually increased by 27% from about $104 per minute in the OR to $132 per minute in the or.

Erica: So that’s a huge win. So what’s driving these trends? First, let’s talk about efficiency. With more experience performing these procedures in the ASC setting, surgeons and staff are naturally moving faster. They’ve had time to refine workflows, optimize processes, and adjust to an outpatient environment.

Erica: That experience translates to shorter OR times while still maintaining quality and safety. Then, of course, there is the technology factor. Advancements in system imaging systems, tools, minimally invasive techniques are making it possible to complete cases faster without sacrificing outcomes. And these innovations are a major reason why we’re seeing shorter OR times.

Erica: But what about the decrease in net revenue per case? So this is [00:19:00] where things get tricky. One possible explanation is, of course, payer reimbursement policies. So even though technology is improving and procedures are becoming more efficient, Payers may not be fully recognizing these advancements in their reimbursement rates. If contracts haven’t been updated to reflect the value of quicker, higher quality procedures, centers might be leaving money on the table. Another factor could be shifts in case volume. If ASCs are handling more lower complexity cardiology cases or increasing volume overall, but at a lower price point, that could contribute to the drop in revenue per case as well.

Erica: So if you’re performing cardiology cases or recently started offering them, take a close look at your payer contracts. See if there’s room for a renegotiation, especially if your case mix has shifted or your OR efficiency and your outcomes have improved. And hopefully when we pull these numbers again in 2025, we’ll see that this trend will start to correct itself.

Erica: But the [00:20:00] bottom line is that cardiology and ASCs is growing, becoming more efficient, and still generating strong revenue. Staying on top of payer policies and contract negotiations will be key to making sure those revenue gains aren’t lost. If you’re interested in more data points and use cases, Subscribe to our podcast so that you don’t miss any upcoming segments or head to our website to check out the full state of the industry report to get your hands on even more data.

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.