A new Dashboard Report is now available for Joint Commission-accredited ambulatory surgery centers (ASCs). It will provide performance measurement data on select measures and is intended to be a springboard for conversations on data, performance measures and quality improvement during the on-site survey process.
The report uses the most recent external data from the Centers for Medicare & Medicaid Services (CMS) ASC Quality Reporting website. After thorough analysis and vetting with national experts from the field, these measures were chosen for the dashboard:
· Patient burn (ASC-1)
· Patient fall (ASC-2)
· Wrong site, side, patient, procedure, implant (ASC-3)
· Hospital transfer/admission (ASC-4)
· Percentage of patients receiving appropriate recommendation for follow-up screening colonoscopy (ASC-9)
· Percentage of patients with history of polyps receiving follow-up colonoscopy in the appropriate time frame (ASC-10)
· Percentage of patients who had cataract surgery and had improvement in visual function within 90 days following the surgery (ASC-11)
· Rate of unplanned hospital visits after an outpatient colonoscopy (ASC-12)
· Percentage of surgical patients under general/neuraxial anesthesia of 60 minutes or more who are normothermic within 15 minutes of arrival in a postanesthesia care unit (ASC-13)
· Percentage of cataract surgery patients who have unplanned anterior vitrectomy (ASC-14)
The report — which can be found in the Continuous Compliance section of an accredited organization’s Joint Commission Connect extranet site — notes each organization’s performance on selected measures and shows that organization’s performance compared to averages at the national, state and Joint Commission level.
While the dashboard is not a scorable element on survey, it can be used as a tool to facilitate discussion about ongoing quality improvement. The Joint Commission plans to release a Dashboard Report for specialty hospitals, such as rehabilitation and inpatient psychiatric, in 2020. For more information about the Dashboard Reports, organizations should contact their account representatives.
