Compare and Improve

Using clinical benchmarking effectively means selecting meaningful benchmarks, making careful comparisons and taking action based on what you learn

By Sandra J. Jones, CASC

Clinical benchmarking has become an essential tool for ASCs looking to improve quality, boost performance and meet the expectations of regulators, payers and patients, but a lot of ASCs are still uncomfortable with it.

The Joint Commission and the Accreditation Association for Ambulatory Health Care list failure to benchmark among their top five or six citations of deficiencies, and about half of all ASCs that went through accreditation in 2011 still did not benchmark, according to an estimate from ASCA and the Outpatient Ophthalmic Surgery Society (OOSS).

In Quality Assurance and Performance Improvement (QAPI) activities, which are mandated by the Centers for Medicare & Medicaid Services (CMS), regulations in many states and ASC accreditors, benchmarking can help you focus on selecting an area for improvement and demonstrate your success.

Starting the Process

Benchmarking involves comparing performance over time, among specialties or individual physicians, or between your ASC and an external source. It can be month to month, quarter to quarter or year to year trending.

Benchmarking involves comparing performance over time, among specialties or individual physicians, or between your ASC and an external source. It can be month to month, quarter to quarter or year to year trending.

To make the most of benchmarking in your ASC, review the items that affect the areas of your operations that show the greatest need for change. For example, choose a high-volume or problem-prone item or one associated with regulatory or standards compliance; or look at measures of operational efficiency such as clinical hours or accounts receivable days.

There are many ways to identify an appropriate item to measure. If you are participating in ASCA Benchmarking, review your individual report and identify items where your performance is not as good as others. ASCA introduced a fully Internet-based clinical and operational ASC benchmarking tool that offers many user-friendly features this year. The report generated by that tool covers more than 40 key indicators, including clinical outcomes, processes and key operational measures.

Internal and External Benchmarking

Internal benchmarking is a good place to start, because it can show variability in a particular process over time, which might indicate a problem. Later in the process, internal benchmarking helps you track performance over time. For example, you might use a chart or a graph to record the number of cases cancelled in pre-op. These cancellations can be a problem for you because they disrupt your schedule and affect your patients, the responsible adult companions who accompany patients to your ASC on the day of surgery, those who provide care for your patients once they return home and a host of other process activities. Your own data might indicate a change in cancellations week to week or month to month and show consistently higher cancellations than you desire. Do these cancellations occur more frequently with particular surgeons or specialties? Were cancellations due to patients who did not follow preoperative instructions, failed to arrive on time or failed to be accompanied by a responsible adult companion? Once you collect the data, you can more thoroughly determine what actions you can take to reduce cancellations

How do you know that you have done as much as you can to reduce cancellations? Do other ASCs have this problem? How much of a problem is it for your ASC when compared to others? Are you about the same? Better? Worse?

That is where external benchmarking can provide information to help you decide what to target as a QAPI activity, and once that decision is made, what to set as a reasonable goal for improvement. The example of cases cancelled provided above is one data element in ASCA Benchmarking. The external benchmarking source helps you understand how much room for improvement you have or how good you can expect to get on a particular measurement because you can see how others performed on the measure. Another example might come to your attention through a staff comment or an adverse event.

Vitrectomy is a known complication of cataract surgery, but how often does it occur at your surgery center? How often does it occur per 1,000 cataract surgeries in any location in the US or abroad? Reports from specialty groups conducting research on complications are available on vitrectomies and other cataract surgery complications. Other specialty groups, such as gastroenterology, anesthesiology, orthopedic surgery and ear, nose and throat (ENT) also publish reports or journal articles that contain valuable data that will help you compare processes and performance to others.

In internal benchmarking, some processes, such as performing a time out, will require 100 percent compliance, while others might never reach 100 percent. Consult external benchmarks to help you pinpoint a reasonable goal, such as 87 percent compliance on hand hygiene.

Sources for External Benchmarks

You might need to consult several sources before you find the right external benchmark for you. And, the more detail that you can get about the measurement, the better. Are you measuring the same thing in the same way? Specialty web sites and journals contain research reports that can help you get the information you need. The Centers for Disease Control and Prevention (CDC) reports statistical findings on various topics, as do the Association of PeriOperative Registered Nurses (AORN) and the Association for Professionals in Infection Control and Epidemiology (APIC). You will want to learn the precise definition of any measure you see in these reports to determine if it matches what you intend to measure.

ASCs that are part of corporations might have ready access to benchmarks from their sister ASCs, but freestanding centers also can get statistics by teaming up with similar facilities. At our surgery centers, we have reviewed supply use and cost by CPT code for some high volume surgical procedures such as knee arthroscopy or tonsillectomy and adenoidectomy (T&A), comparing center to center and doctor to doctor. Currently, we are working with several orthopedic surgery centers to share data on the in¬terval between start of anesthesia and cut time for shoulder cases since this interval impacts patient safety, cost and the scheduling of staff and cases.

Act on the Results

A lot of centers simply collect data and benchmarks and never take the next step of evaluating the information to determine if there is an opportunity to improve, and, if so, take action.

Even fairly modest variations might deserve action. For example, if your infection rate is 1.5 percent per 1,000 cases versus an external benchmark showing 1 percent, this variance indicates an opportunity for improvement. The next step will be determining what exactly is causing the higher rate. Share your data with members of your governing board. Ask them for suggestions on additional data to collect or areas to research. Involve them in reviewing your findings and discussing an action plan. It is important to document the discussion to demonstrate your governing body’s participation in QAPI.

Keep in mind that benchmarking is an ongoing process. It is not a static, one-time event. There are some processes or outcomes that you will always review, and there are times you can stop measuring the same thing again and again because you are equal to or above your goal. Once you achieve or exceed your goal, look for a new item to measure and a new opportunity to move forward into a QAPI project to demonstrate improvement in patient care.


When surveyors ask about benchmarking, ASCs sometimes forget to mention all of the the benchmarking activities they are conducting. Your participation in reporting G-codes on your claims is an important benchmark of quality measures. Are you checking month to month what you are reporting to spot any trends that might indicate a need for action? Are you participating in ASCA Benchmarking so that you can compare your rate of patient burns, falls, wrong procedure/site and timeliness of antibiotic administration to other ASCs? And, wouldn’t you want to know how you stand on these particular measures before CMS publishes information or changes your reimbursement, which might occur in the future?

Let Surveyors Know

Instead of laying down a rigid set of activities for all centers, benchmarking helps a center concentrate on its own unique areas where an improvement plan can have the greatest impact. Would you want to spend time collecting more data and analyzing it when a particular benchmark shows you are already a top of performer? Knowing where you stand on certain key performance indicators (KPIs) can help you dedicate your resources to improving performance and outcomes and demonstrate your results.

Sandra J. Jones, CASC, is the chief executive officer of Ambulatory Strategies Inc. in Dade City, Florida. Write her at