Quality Measures Developed and Tested by the ASC Quality Collaboration

ASC QC Executive Leaders review annually, along with CMS Measure Information Forms.

Both guides are updated on an annual basis. Here is the Measures Summary and the Implementation Guide.

See the link to the quality reporting program for CMS measure information and requirements. https://qualitynet.cms.gov/asc/ascqr/measures. The measures specification guide depicts which measures are currently mandatory.

Yes, the tools can be found in the Implementation Guide.

These two measures have been retired from the benchmarking report since the 2019 quality data was posted. The specifications for these two measures are still included in the Implementation Guide.

Intent or Rationale for Measure: Falls are an important issue for patients having outpatient procedures or surgery because virtually all patients receive sedatives, anesthetics and/or pain medications as a routine part of their care. The use of these medications increases the likelihood of a fall.

Description of Measure:
This measure is used to assess the number of admissions (patients) that experience a fall within the ASC

Numerator/Denominator for Measure:
Numerator: Ambulatory Surgery Center (ASC) admissions experiencing a fall within the confines of the ASC
Denominator: All ASC admissions

Inclusion/Exclusion Items for the Measure:
Numerator Inclusion: ASC admissions experiencing a fall within the confines of the ASC
Numerator Exclusion: ASC admissions experiencing a fall outside the ASC
Denominator Inclusion: All ASC admissions
Denominator Exclusion: ASC admissions experiencing a fall outside the ASC

Where can I find more details?

• Implementation Guide
• Prevention of Patient Falls Toolkit

FAQs

1) Should we count assisted falls under this measure? Yes, assisted falls are considered falls for the purposes of this measure.

2) What about falls in the parking lot? Should those be counted? The physical plant and location of ASCs is highly variable. To assure that the measure would be applicable to all settings, reportable falls are limited to those that occur within the confines of the facility itself. Falls in the parking lot should not be counted.

3) Should we count falls that are not witnessed? All patient falls are counted, regardless of whether they are witnessed or not.

4) Does the ASC QC offer resources for falls prevention? Yes, the ASCQC has a Prevention of Patient Falls Toolkit.

Intent or Rationale for Measure: Burns are an important issue for patients having outpatient procedures or surgery because the equipment and supplies routinely used in providing these types of services can increase the risk that a patient will experience an unintended burn.

Description of Measure:
This measure is used to assess the number of admissions (patients) that experience a burn prior to discharge

Numerator/Denominator for Measure:
Numerator: Ambulatory Surgery Center (ASC) admissions experiencing a burn prior to discharge
Denominator: All ASC admissions

Inclusion/Exclusion Items for the Measure:
Numerator Inclusions: ASC admissions experiencing a burn prior to discharge
Numerator Exclusions: None
Denominator Inclusions: All ASC admissions
Denominator Exclusions: None

Where can I find more details?

• Implementation Guide

FAQs

1) Do all ASCs have conditions that would result in a patient burn? Yes, because the definition of burn in this measure is comprehensive, every ASC has the potential for a patient to experience a burn during an episode of care.

2) Did the ASC Quality Collaboration consider stratifying by type of burn? Stratification by type of burn was considered, but the consensus of the workgroup was that a burn is an unexpected outcome in an ASC and should not occur regardless of the source, degree or type of burn.

Intent or Rationale for Measure: The need for transfer/admission is an unanticipated outcome and could be the result of insufficient rigor in patient or procedure selection. Hospital transfers/admissions can result in unplanned cost and time burdens that must be borne by patients and payers. While hospital transfers and admissions undoubtedly represent good patient care when necessary, high rates may be an indicator that practice patterns or patient selection guidelines are in need of review. It should be noted that issues identified preoperatively are included because they also represent good patient care when a hospital transfer/admission is necessary.

Description of Measure:
This measure is used to assess the percentage of ASC admissions (patients) that are transferred or admitted to a hospital upon discharge from the ASC

Numerator/Denominator for Measure:
Numerator: Ambulatory Surgery Center (ASC) admissions requiring a hospital transfer or hospital admission upon discharge from the ASC
Denominator: All ASC admissions

Inclusion/Exclusion Items for the Measure:
Numerator Inclusions: ASC admissions requiring a hospital transfer or hospital admission upon discharge from the ASC, including preoperative transfers or admissions.
Numerator Exclusions: None
Denominator Inclusions: All ASC admissions
Denominator Exclusions: None

Where can I find more details?

• Implementation Guide

FAQs

1) Should patients who go to a hospital emergency room sometime after their discharge be counted? To allow consistent reporting, only patients who are directly transferred or directly admitted to the hospital upon their discharge from the ASC are counted for purposes of this measure.

2) Do we count ASC patients who are admitted to the hospital sometime after their discharge from the ASC secondary to a complication of surgery? No, only patients who are directly transferred or admitted to the hospital upon their discharge from the ASC should be counted.

3) Do we capture data for all ASC patients who are directly transferred or admitted to the hospital setting regardless of reason? Yes, all transfers or admissions to the hospital that take place upon discharge from the ASC should be counted, regardless of the reason for the transfer or admission.

4) Do we count a patient who was transferred to the emergency room because an issue was identified in pre-op? Yes, patients with issues identified in pre-op that are transferred or admitted to a hospital/emergency room directly from the ASC are counted.

5) Do we count patients who are transferred to the hospital setting in an automobile upon discharge? Yes. All transfers or admissions upon discharge from the ASC are counted, regardless of the mode of transportation.

Intent or Rationale for Measure: Surgery or other invasive procedure performed on the wrong site”, “surgery or other invasive procedure performed on the wrong patient”, and “wrong surgical or other invasive procedure performed on a patient” have all been endorsed as serious reportable surgical events by NQF. This outcome measure serves as an indirect measure of providers’ adherence to the Joint Commission’s “Universal Protocol” guideline for eliminating wrong site, wrong procedure, wrong person surgery. The Universal Protocol is based on the consensus of experts and is endorsed by more than forty professional medical associations and organizations. To encompass the outcomes of all key identification verifications, the ASC Quality Collaboration’s measure incorporates not only wrong site, wrong side, wrong patient and wrong procedure, but also wrong implant in its specifications.

Description of Measure:
This measure is used to assess the number of ASC admissions (patients) that experience a wrong site, side, patient, procedure or implant

Numerator/Denominator for Measure:
Numerator: All Ambulatory Surgery Center (ASC) admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or wrong implant
Denominator: All ASC admissions

Inclusion/Exclusion Items for the Measure:
Numerator Inclusions: All ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or wrong implant
Numerator Exclusions: None
Denominator Inclusions: All ASC admissions
Denominator Exclusions: None

Where can I find more details?

• Implementation Guide

FAQs

1) Isn’t the incidence of wrong site, etc. surgery low in surgery centers? While the incidence of wrong-site surgeries is low, the potential for wrong-site (bilateral options) and the impact on patient care associated with each incident make this a priority in ASCs.

2) Do you count a block (preoperative or intraoperative) given on the incorrect side? Yes, you count any procedure that was done on the wrong side.

3) Do you count an injection of local given on the incorrect side? Yes, you count this as a wrong side event. Should the administration of topical anesthetic drops in the wrong eye be considered a wrong site event? No, administration of topical anesthetic drops in the wrong eye should not be counted as a wrong site event. Such an occurrence would be considered a medication administration variance.

4) Is the placement of an expired implant considered a wrong implant event? Yes, the placement of an expired implant is considered a wrong implant event. Such an occurrence is not considered to be in accordance with the intended implant.

5) Should the administration of topical anesthetic drops in the wrong eye be considered a wrong site event? No, administration of topical anesthetic drops in the wrong eye should not be counted as a wrong site event. Such an occurrence would be considered a medication administration variance.

6) A patient is scheduled for a right carpal tunnel release, but the left side was done. The patient was going to need the left one done in the future. Should this be reported as a wrong side? Yes, this would be considered a wrong side event. It was not the procedure that was consented for or intended to be performed that day, even though both sides were eventually going to be done.

7) During an orthopedic case, a screw was placed but then intentionally replaced with one determined to be a better fit. Should this be reported as a wrong implant? No, this would not be reported as a wrong implant. The decision to change the screw was intentional to achieve a better fit. The change did not result from an error in implantation of the first screw.

8) During a knee arthroplasty, an incorrect tibial insert was handed to the surgeon and implanted. The incorrect insert was subsequently removed prior to closure, and the correct implant was placed. Should this be reported as a wrong implant? Yes, this would be reported as a wrong implant event. The placement of the first implant was unintentional and in error.

Intent or Rationale for Measure: Despite advances in infection control practices, surgical site infections remain a substantial cause of morbidity and mortality among hospitalized patients. Studies indicate that appropriate preoperative administration of antibiotics. Systemic and process changes that promote compliance with established guidelines and standards can decrease infectious morbidity.

Description of Measure:
This measure is used to assess whether antibiotics given for prevention of surgical site infection were administered on time

Numerator/Denominator for Measure:
Numerator: Number of Ambulatory Surgery Center (ASC) admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infection, who received the prophylactic antibiotic on time
Denominator: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of surgical site infection

Inclusion/Exclusion Items for the Measure:
Numerator Exclusions: None
Denominator Exclusions: ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of infections other than surgical site infections (e.g. bacterial endocarditis); ASC admissions with a preoperative order for a prophylactic antibiotic not administered by the intravenous route

Where can I find more details?

• Implementation Guide

FAQs

1) For prophylactic antibiotics, do we only count those ordered for IV administration? Not eye drops when used for the same purpose? Only patients with orders that specify an intravenous route of administration should be counted.

2) If an antibiotic is ordered that is not included in the list of prophylactic antibiotics for this measure, should we count it? No, the only antibiotics that are considered for inclusion in this measure are those that are included in the definition of “prophylactic antibiotic”.

3) If an antibiotic is ordered for the prophylaxis of spontaneous bacterial endocarditis (SBE), should we count it? No, the only antibiotics administered for the prophylaxis of surgical site infection are included for measurement.

4) What happens when two or more prophylactic antibiotics are given to the same patient for the same procedure? The infusion of all prophylactic IV antibiotics ordered for surgical site infection would need to be initiated within the one-hour time frame (two hours for vancomycin or fluoroquinolones). In cases involving more than one antibiotic, all antibiotics must be initiated within the appropriate time frame in order for the case to meet criteria.

5) Does the timing of the antibiotic start at the completion of the antibiotic or the start of the antibiotic? The timing begins at the time the antibiotic infusion is initiated. To meet the intent the antibiotic should be initiated within one hour of the initial surgical incision or the beginning of the procedure (two hours for vancomycin or fluoroquinolones).

6) Do you include patients who do not have an order for prophylactic IV antibiotics? Patients without an order for prophylactic IV antibiotics are not included.

7) If the order for the antibiotic is given after the procedure has started, should the case be counted? If the order for the antibiotic is given after the procedure has started, the case should not be included. The denominator for this measure specifically requires a preoperative order.

8) This measure is difficult to track. Why did you develop an IV antibiotic timing measure? Evidence shows initiating prophylactic antibiotics within one hour of incision, procedure, or tourniquet results in better outcomes.

9) Is tourniquet time a substitute for incision time? Tourniquet time is included based on published studies that demonstrate higher tissue concentrations of prophylactic antibiotics when the administration is prior to tourniquet inflation. The use of tourniquet time is consistent with the American Academy of Orthopedic Surgery Advisory Statement that recommends infusion prior to inflation of a proximal tourniquet, rather than prior to incision.

10) How do I collect data for this measure? A sample data collection log is available in Appendix B of the Implementation Guide.

Intent or Rationale for Measure: Razors can cause microscopic cuts and nicks to the skin, not visible to the unaided eye. Use of razors prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use, or no hair removal at all.

Description of Measure:
This measure is used to assess the percentage of admissions (patients) that have appropriate surgical site hair removal

Numerator/Denominator for Measure:
Numerator: ASC admissions with surgical site hair removal with a razor or clippers from the scrotal area, or with clippers or depilatory cream from all other surgical sites
Denominator: All ASC admissions with surgical site hair removal

Inclusion/Exclusion Items for the Measure:
Numerator Inclusions: ASC admissions with surgical site hair removal with a razor or clippers from the scrotal area, or with clippers or depilatory cream from all other surgical sites
Numerator Exclusions: None
Denominator Inclusions: All ASC admissions with surgical site hair removal
Denominator Exclusions: ASC admissions who perform their own hair removal

Where can I find more details?

• Implementation Guide

FAQs

1) Do we capture data for all patients who are admitted to the ASC? No, only those patients with surgical site hair removal are counted.

2) Do we count ASC patients who shave themselves? No, ASC admissions that perform their own hair removal are excluded.

3) How do I collect data for this measure? A sample data collection log is available in Appendix B of the Implementation Guide.

Intent or Rationale for Measure: Impairment of thermoregulatory control due to anesthesia may result in perioperative hypothermia. Hypothermia, even when mild, is associated with consequences such as increased susceptibility to infection, impaired coagulation, cardiovascular stress and cardiac complications, as well as post-anesthetic shivering and thermal discomfort.

Description of Measure:
This measure is used to assess the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration are normothermic within 15 minutes of arrival in PACU

Numerator/Denominator for Measure:
Numerator: Surgery patients with a body temperature equal to or greater than 96.8 Fahrenheit/36 Celsius recorded within fifteen minutes of Arrival in PACU
Denominator: All patients, regardless of age, undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes duration

Inclusion/Exclusion Items for the Measure:
Numerator Exclusions: Patients with a postoperative body temperature less than 96.8 Fahrenheit/36 Celcius; patients whose body temperature was recorded sixteen minutes or more after arrival in PACU; patients with no postoperative body temperature recorded.
Denominator Exclusions: Patients who did not have general or neuraxial anesthesia; patients whose length of anesthesia was less than 60 minutes; patients with physician/APN/PA documentation of intentional hypothermia for the procedure performed

Where can I find more details?

• Implementation Guide

FAQs

1) If the patient receives local or regional anesthesia, should they be included? No, only patients having surgery under general or neuraxial anesthesia should be included in the denominator.

2) This patient was under general anesthesia for 60 minutes. Should they be counted? Yes, any patient having general anesthesia that lasts for 60 minutes or more should be counted in the denominator.

3) We checked this patient’s temperature 16 minutes after they arrived in PACU and it was 98.7 F. Since they were normothermic, do we count them in the numerator? No, only patients who were normothermic within 15 minutes of arrival in PACU can be included in the numerator.

4) We forgot to check a patient’s temperature after surgery. Do we count them in the numerator? No, without documentation that the patient was normothermic within 15 minutes of arrival in PACU the patient cannot be included in the numerator.

5) Our center does not have a formal PACU. Patients recover in their pre-op room. Should these patients be counted? Yes, these patients should be counted. Other locations in the center may, for purposes of this measure, function as a space for post-anesthesia recovery in the facility.

6) Is the start of anesthesia the same as the start of anesthesia billing time? No. The basis for this measure is the physiologic impairment in temperature regulation associated with the administration of general/neuraxial anesthesia. It is not related to billing time.

7) Is it possible to have a measure score greater than 100%? No. The numerator cannot be larger than the denominator. To use the measure, first identify the patients that meet the criteria outlined in the denominator, and then evaluate each of those patients to see if they meet the criteria defined in the numerator. For example, if you identify 100 patients that meet the denominator criteria, you will then evaluate each of those 100 patients to determine which of them meet the numerator criteria. A score of 100% is the maximum possible.

8) How do I collect data for this measure? A sample data collection log is available in Appendix B in the Implementation Guide.

Intent or Rationale for Measure: The need for unplanned anterior vitrectomy is an unanticipated event that can decrease the probability of good postoperative visual acuity, and generally result in worse long-term outcome after cataract surgery. Because cataract surgery is the most common surgery performed in ASCs, with millions being performed every year, even low unplanned anterior vitrectomy rates translate to relatively high total numbers of affected patients. ASCs can help keep rates low by tracking and comparing rates to established benchmarks, and facilitating mentoring as needed.

Description of Measure:
This measure is used to assess the percentage of cataract surgeries that have an unplanned anterior vitrectomy

Numerator/Denominator for Measure:
Numerator: All cataract surgeries that had an unplanned anterior vitrectomy
Denominator: All cataract surgeries

Inclusion/Exclusion Items for the Measure:
Numerator Exclusions: None
Denominator Exclusions: None

Where can I find more details?

• Implementation Guide

FAQs

1) One of our cataract surgery patients was also scheduled for an anterior vitrectomy. Should this patient be counted? No, only patients who had an unplanned anterior vitrectomy should be counted.

2) Do we count all our patients who are having any kind of intraocular surgery? No, only cataract surgeries should be included in the denominator.

3) How could a facility benefit from this measure? If unplanned anterior vitrectomies are determined to be at a level higher than expected, ASCs could facilitate mentoring within their facility.

Intent or Rationale for Measure: Toxic anterior segment syndrome (TASS), an acute, noninfectious inflammation of the anterior segment of the eye, is a complication of anterior segment eye surgery that typically develops within 24 hours after surgery. Various contaminants, including those from surgical equipment or supplies, have been implicated as causes of TASS. Although most cases of TASS can be treated, the inflammatory response associated with TASS can cause serious damage to intraocular tissues, resulting in vision loss. Prevention requires careful attention to solutions, medications, and ophthalmic devices and to cleaning and sterilization of surgical equipment because of the numerous potential etiologies. Despite a recent focus on prevention, cases of TASS continue to occur, sometimes in clusters. With millions of anterior segment surgeries being performed in the United States each year, measurement and public reporting have the potential to serve as an additional tool to drive further preventive efforts.

Description of Measure:
This measure is used to assess the number of anterior segment surgery patients diagnosed with TASS within 2 days of surgery

Numerator/Denominator for Measure:
Numerator: All anterior segment surgeries after which the patient is diagnosed with TASS within 2 days of surgery Denominator: All anterior segment surgeries

Inclusion/Exclusion Items for the Measure:
Numerator Exclusions: None
Denominator Exclusions: None

Where can I find more details?

• Implementation Guide

FAQs

1) Do we count all our patients who are having some kind of intraocular surgery? No, only patients having anterior segment surgery should be included in the denominator.

2) What day is considered to be day 2? For purposes of this measure, the day of surgery is day 0. So, day 2 would be the second day following the day of surgery. For example, if July 1 were the day of surgery, day 2 would be July

Intent or Rationale for Measure: An emergency department visit within the first day of ASC discharge is an unanticipated outcome that results in unplanned cost and time burdens that must be borne by patients and payers. While emergency department visits undoubtedly represent good patient care when necessary, high rates may be an indicator that practice patterns or patient selection guidelines are in need of review.

Description of Measure:
This measure is used to assess the percentage of ASC admissions (patients) that have an emergency department visit within one day of discharge from the ASC.

Numerator/Denominator for Measure:
Numerator: All ASC admissions who had an emergency department visit within one day of discharge from the ASC.
Denominator: All ASC admissions

Inclusion/Exclusion Items for the Measure:
Numerator Exclusions: ASC admissions who were transferred/admitted directly to an acute care hospital, including a hospital emergency room, upon discharge from the ASC (report using Hospital Transfer/Admission measure); ASC admissions who had an unplanned hospital admission within one day of being discharged from the ASC (report using All-Cause Unplanned Hospital Admission Within One Day of Discharge measure)
Denominator Exclusions: None

Where can I find more details?

• Implementation Guide

FAQs

1) Should patients who are transferred directly from the ASC to a hospital emergency room be counted? No, only patients who have an emergency department visit following their discharge from the ASC should counted for purposes of this measure.

2) Do we count ASC patients who are admitted to the hospital within one day of their discharge from the ASC? No, only patients who have an emergency department visit following their discharge from the ASC should be counted. ASC admissions that had an unplanned hospital admission within one day of being discharged from the ASC should be reported using the All-Cause Unplanned Hospital Admission Within One Day of Discharge measure.

3) Do we capture data for all ASC patients who are directly transferred or admitted to the hospital setting regardless of reason? Yes, all emergency room visits that take place within one day of discharge from the ASC should be counted, regardless of the reason.

4) How do I collect data for this measure? To ensure reliable results, this measure must be implemented using the ASC QC Post Discharge Surveillance Protocol, which can be found in Appendix C in the Implementation Guide.

Intent or Rationale for Measure: An unplanned hospital admission within the first day of ASC discharge is an unanticipated outcome that results in unplanned cost and time burdens that must be borne by patients and payers. While hospital admission undoubtedly represents good patient care when necessary, high rates may be an indicator that practice patterns or patient selection guidelines are in need of review.

Description of Measure:
This measure is used to assess the percentage of ASC admissions (patients) that have an unplanned hospital admission, including an observation stay, within one day of discharge from the ASC.

Numerator/Denominator for Measure:
Numerator: All ASC admissions who had an unplanned hospital admission within one day of discharge from the ASC. Denominator: All ASC admissions

Inclusion/Exclusion Items for the Measure:
Numerator Exclusions: ASC admissions who were transferred/admitted directly to an acute care hospital, including a hospital emergency room, upon discharge from the ASC (report using ‘Hospital Transfer/Admission’ measure); ASC admissions who had a visit to the emergency department of an acute care hospital within one day of discharge that did not result in an admission to the hospital (report using All-Cause Emergency Department Visit Within One Day of Discharge measure); ASC admissions who had a previously planned hospital admission within one day of discharge from the ASC.
Denominator Exclusions: None

Where can I find more details?

• Implementation Guide

FAQs

1) Should patients who are transferred directly from the ASC to a hospital be counted? No, only patients who have an unplanned hospital admission following their discharge from the ASC should be counted for purposes of this measure.

2) Do we count ASC patients who have an emergency department visit within one day of their discharge from the ASC? No, only patients who have an unplanned hospital admission following their discharge from the ASC should be counted. ASC admissions that had an emergency department visit within one day of being discharged from the ASC should be reported using the All-Cause Emergency Department Visit Within One Day of Discharge measure.

3) Do we count ASC patients who have a hospital observation stay within one day of their discharge from the ASC? Yes, for purposes of this measure, an observation stay that occurs within one day of discharge from the ASC is considered an unplanned hospital admission.

4) Do we capture data for all ASC patients who are admitted to the hospital within one day of discharge regardless of reason? All unplanned hospital visits that take place within one day of discharge from the ASC should be counted, regardless of the reason. Planned hospital admissions that occur within one day of ASC discharge should not be counted.

5) How do I collect data for this measure? To ensure reliable results, this measure must be implemented using the ASC QC Post Discharge Surveillance Protocol, which can be found in Appendix C of the Implementation Guide.