Quality Measures Developed and Tested by the ASC Quality Collaboration
The ASC Quality Collaboration has developed 11 quality measures. The definitions of those 11 measures are included below and can be found in the Implementation Guide and the Measures Summary. The ASC Quality Collaboration Benchmarking report currently includes 9 measures (IV Antibiotic Timing and Appropriate Hair Removal were retired from the benchmarking report in 2019).
Common Questions
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How are measures reviewed and updated?
ASCQC Executive Leaders review annually, along with CMS Measure Information Forms.
How often are the Implementation Guide and Measures Specification Guide reviewed and updated?
Both guides are updated on an annual basis. Here is the Measures Summary and the Implementation Guide.
Which measures are required for reporting through the CMS quality reporting program?
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.
Are there tools available for data collection on the measures?
Yes, the tools can be found in the Implementation Guide.
Why are the Prophylactic IV Antibiotic Timing and Appropriate Surgical Site Hair Removal measures not included on the benchmarking report?
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.
Quality Measures
The six measures currently mandated by CMS for ASC quality reporting are depicted with an *.
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Patient Fall in the ASC*
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?
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.
Patient Burn*
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?
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.
All Cause Hospital Transfer/Admission*
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 calculated to produce a rate per 1,000 admissions for 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?
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.
Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant*
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?
FAQs & Scenarios
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) Scenario #1: Patient A is expected, patient B is brought into the OR. Prep and drape are startedPhysician enters the OR and a time out is performed-the wrong patient mistake is identified. Lens and all documentation are swapped for patient in the room, no harm. Should this be reported as a wrong patient or a near miss/good catch? Answer: This case would be reported as a near miss/good catch because the mistake was identified and everything was subsequently done correctly for the patient who was brought into the OR. There was no harm to the patient. The evaluation of the near miss should include a review of the process by which the wrong patient was brought into the OR.
Note AHRQ definition of near miss: Near miss: an unsafe situation that is indistinguishable from a preventable adverse event except for the outcome. A patient is exposed to a hazardous situation, but does not experience harm either through luck or early detection.
3) Scenario #2: The OR is set up for patient A. Pt B is wheeled in. They are for the same procedure on the same side (no implant or the exact same implant). Identity is discovered at the end of the procedure. No harm occurred. Should this be reported as a wrong patient? Answer: Yes, this case would be reported as a wrong patient despite the fact that the procedure for which the patient consented was performed. However, all of the pre-op checks should have identified the incorrect patient prior to start of the case. The process needs evaluation and development of a corrective action plan to prevent similar incidents that could result in more significant outcomes.
4) Scenario #3: Patient scheduled for cataract surgery on the left eye. Patient received two sets of drops in left eye. Provider administered one drop of compounded drop (phenylephrine, tropicamide lidocaine) in right eye just prior to procedure. Should this be reported as a wrong site? Answer: No, this would be reported as a medication administration variance. (correlates with language in the ASC QC Implementation Guide 12.0 January 2024).
5) Scenario #4: Tropicamide 1% and phenylephrine 2.5% drops were given to patient in right eye. Should have been pilocarpine drop. Should this be reported as a wrong site? Answer: No, this would be reported as a medication administration variance.
6) Scenario #5: Avastin Injection (not on ASC formulary) was administered to several patients. The medication was being transported from one location to another by the physician. The MD felt in her professional opinion that the medication was still at an adequate temperature for use. Should this be reported as a wrong site? Answer: No, this would be reported as a medication administration variance.
7) Scenario #6: Right shoulder surgery was scheduled and consented for. The anesthesia provider, in error, injected the local anesthetic (block) in the left shoulder. Should this be reported as a medication error, or is this a wrong side? Answer: This would be reported as a wrong side. This is an invasive procedure that was intended for the right shoulder and the block was performed on the left.
8) Scenario #7: An intraocular lens was placed in the patient and after insertion, it was identified to be the wrong lens. Prior to leaving the operating room, the incorrect lens was removed and replaced with the lens intended for the patient. Should this be reported as a near miss/close call or wrong implant? Answer: This would be reported as a wrong implant because an unintended lens was placed in the patient. The patient had to undergo a second procedure because of the error. The fact that the patient had not left the OR does not impact the determination of wrong implant vs close call/near miss.
9) Scenario #8: Patient was scheduled for cataract removal/IOL. During the time out, an error in lens power was caught before it was placed in the patient. The correct lens was placed in the patient. Should this be reported as a wrong implant or a near miss/good catch? Answer: This would be reported as a near miss/good catch.
10) Scenario #9: Following the insertion of an IOL, it was discovered that the lens that had been implanted was expired. The expired lens was replaced. Should this be reported as a wrong implant? Answer: The placement of an expired implant should be reported as a wrong implant event. Such an occurrence is not considered to be in accordance with the intended implant.
11) Scenario #10: Tympanoplasty right ear with right ear skin graft was scheduled and consented for. Local injection for graft site was done behind left ear. Should this be reported as a medication error, near miss/close call, or wrong site? Answer: This would be reported as a wrong site (wrong side). This is an invasive procedure that was consented to by the patient and intended for the right side.
12) Scenario #11: Epidural Steroid Injection- The physician starts the procedure by inserting a needle and then identifies this is the incorrect side and proceeds to do the injection on the correct side. Would this be reported as a near miss/good catch or a wrong site? Answer: This would be reported as a wrong site (wrong side). This is an invasive procedure that was consented for by the patient and intended for the other side.
Determination would be the same if injection of the local had occurred (not just insertion of needle).
13) Scenario #12: Patient admitted for a Right Knee Replacement. In the OR, prior to closure of the incision, the incorrect tibial insert (poly) was handed to the surgeon for implantation. Even though the correct measurements had been used, the incorrect implant was inserted. The incorrect poly was removed, and the correct implant was inserted. Should this be reported as a near miss/close call or a wrong site? Answer: This would be reported as a wrong site (wrong implant). It did not involve an intentional decision to place the first (incorrect) implant. An error was made. See Scenario below in which there was an intentional decision by the surgeon to place a second implant.
14) Scenario #13: During an Orthopedic case, a screw is placed but then replaced with one that is determined by the surgeon to be a better fit. The screw was intentionally changed. Should this be reported as a wrong implant? Answer: No, this would not be reported as a wrong implant. The choice by the physician to change the screw was intentional and based on what was determined to be a better fit. The change did not result from an error in implantation of the first screw. This was an intentional change in the plan.
15) Scenario #14: Patient is scheduled for a right carpal tunnel release, but the left side was done. It was not discovered until the surgery was complete. The patient was going to need the left one done in the future. Should this be reported as a wrong side? Answer: Yes, this would be reported as a wrong site (wrong side). It was not the procedure that was consented for or intended to be performed that day, despite the fact that both sides were eventually going to be done.
NOTES:
- Regarding injections administered for local anesthesia, if a needle is inserted into the wrong site or side without injection of any medication, this should be reported as a wrong site/side. The intent was not to administer a local to that site. It would be reported the same way if the needle is inserted and local medication is administered to the wrong site.
- If a physician changes the plan of care during the surgery based on what is best for the patient or incidental findings during the surgery, this is not considered an error/wrong site.
- If the ASC receives incorrect information from a surgeon’s office, but the office does not realize or correct it until after the patient’s surgery, and the ASC performs the procedures as ordered, the ASC would not need to report this as a wrong. This assumes that all of the established safety checks were undertaken by the ASC staff.
- Evaluation needs to take place on a case by case basis.
Prophylactic IV Antibiotic Timing
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?
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.
Appropriate Surgical Site Hair Removal
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?
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.
Normothermia*
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?
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.
Unplanned Anterior Vitrectomy*
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?
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.
Toxic Anterior Segment Syndrome
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?
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
All-Cause Emergency Department Visit Within One Day of Discharge
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?
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.
All-Cause Unplanned Hospital Admission Within One Day of Discharge
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?
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.
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