ASCs and Benchmarking: Overcoming Data Challenges to Identify Operational, Clinical Improvements

There is no longer any question as to whether an ambulatory surgery center (ASC) should invest resources in developing internal benchmarking programs. Federal pay-for-performance initiatives that were hanging in the balance for a number of years are now unfolding, while indications from accrediting organizations and private payers point to more scrutiny surrounding quality and enhanced care delivery.

As of October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) ASC Quality Reporting Program began requiring reporting on five measures: falls, burns, hospital transfers, wrong-site surgeries and improperly timed antibiotic administrations.i Performance on these measures will affect payment determinations beginning in CY2014, and the information will be made public. If an ASC's performance does not measure up against its peers regionally and nationally, the resulting fallout could impact public perception and future viability.

To meet current and future quality expectations and to be accountable for the care they provide, ASCs need to establish a baseline of performance metrics to determine where improvements are needed. Internal benchmarking programs lay the foundation for identifying internal clinical and administrative processes in need of refinement, as well as enabling the tracking of quality improvement progress. When ASCs are armed with clear data, they can compare their standing in relation to local and national peers and identify potential areas of weakness that impact revenue.

Initiatives like the Ambulatory Surgery Center Association's Outcomes Monitoring Project are helping to provide ASCs with the national data needed for benchmarking. Currently more than 650 participants are submitting data for 41 key indicators that enable comparisons with national performance statistics.ii Additionally, the Medical Group Management Association conducts annual surveys that revolve around compensation, revenue, expenses, and the like, which many ASC administrators utilize when auditing practice performance. iii A number of specialty-specific private reporting initiatives are also underway. These include the GI Quality Improvement Consortium (GIQuIC)iv, the National Quality Forum (NQF)v, and the CMS Physician Quality Reporting System (PQRS)vi.

Every aspect of an ASC's operations can fall under the benchmarking microscope. From a clinical perspective, ASCs can start with OR utilization, IV starts, infection rates, post-operative complications, hospitalization rates, medication utilization, hand-washing and time-outs. Administrative considerations could include staff turnover, staff education, claims denials, time to bill, days in accounts receivable, scheduling, registration and patient education.

The challenge underlying many ASCs' attempts to efficiently and effectively take benchmarking and quality reporting to the next level is the existence of manual, paper-based processes. That was the reality facing Fort Worth Endoscopy Center (FWEC) when, after 15 years, the organization set out to expand its quality-tracking practices to comprehensively cover more operational and clinical measures, as well as benchmark against national standards. A pilot participant in GIQuIC, FWEC soon realized that managing the effort manually was too cumbersome and time-consuming.vii

The same issue held true for Gastroenterology Associates of Central Virginia (GACV). In attempting to establish internal benchmarking, the organization found not only that resources were limited with paper-based processes but also that the data collected was not always consistent or accurate.viii

The Challenge of Efficiently Capturing Accurate and Compliant Data

Despite the benefits of internal and external benchmarking, many ASCs face several key obstacles that must be overcome before they can establish effective programs. First, physician documentation must be accurate and reflect the data needs of the benchmarking process. Traditional dictation and transcription models lead to inconsistent presentation of information, making it difficult to accurately capture meaningful quality data.

Specifically, FWEC found that dictated reports often resulted in incomplete data capture, and the complexities of trying to extrapolate data elements to match key quality indicators - such as cecal intubation or quality of bowel prep - was cumbersome at best.ix Incomplete data was also a problem for GACV, as were inconsistencies associated with having too many staff members involved in the collection process. Duplications and misinterpretations of data led to additional inconsistency.x

Because many ASCs are still not leveraging the benefits of advanced automation and electronic health records (EHRs), participation in internal and national benchmarking initiatives has been hampered due to the inability to confidently capture structured, compliant data. In general, manual data collection is resource-intensive and error-prone. Locating discrete data elements for reporting is challenging since there is no way to efficiently query for information. The end result is inconsistent and incomplete data that, once reported, does not advance the goals of initiatives to provide meaningful comparisons.

Meeting the Benchmarking Challenge

A 2008 independent study found that 82 percent of ASCs were not utilizing an EHR and 74 percent used dictation and transcription to generate physician procedure notes. The study also revealed that the primary barriers to EHR deployment were investment costs and revenues lost during implementation.xi

When considering the potential return on an EHR investment in terms of streamlining and improving workflows and patient care, it becomes clear that these perceived barriers are flawed. Add the value derived from accurate benchmarking and efficient participation in regulatory reporting initiatives to the inherent operational and clinical benefits, and the case for an EHR becomes an easy one to make.

GACV, a physician-owned, Accreditation Association for Ambulatory Health Care-accredited ASC that encompasses seven physicians and five nurse practitioners, was able to increase billing and coding accuracies from 45 percent under manual processes to 95 percent following the deployment of EHR procedure documentation software. The organization also saw patient satisfaction rates jump from 97.9 percent to 99.5 percent. Increased charting and scheduling efficiencies drove reduction in overtime and staff expenses, and staff members are now able to perform daily chart audits to identify areas where additional clinical education may be needed.xii

Specific to benchmarking, procedure documentation software allows many of the required data points to be collected directly from procedure notes. Pulling from structured content provided via drop-down menus, physicians are able to choose from standardized clinical terminology, eliminating the potential for duplicate data entry and ensuring consistency.

In contrast to unstructured content, or free text, structured content is tagged or coded data that resides in a fixed field where it can be located and identified. When this content is indexed at a granular level, it ensures that more data points can be collected without any additional resources, and specific data points can be flagged to eliminate reporting gaps.

For GACV, automating the data capture and reporting process this way allows the organization to monitor a significant number of key metrics that drive quality, productivity and financial performance. GACV currently uses procedure documentation software to monitor:

  • Cecal intubation rates
  • Adenoma rates
  • Medication utilization by clinician
  • Case numbers per physician
  • Time management
  • Room turnover
  • Chart auditing
  • Follow-up calls
  • Nursing at bedside
  • Time to billxiii

In relation to the GIQuIC initiative, FWEC has specifically targeted benchmarking of colonoscopy performance for colorectal cancer screening to improve both the quality and the cost-effectiveness of practices. The end result has been a change in practice behaviors that is more in line with the latest industry evidence. For example, physicians are now spending more time examining the colon during withdrawal, which increases the average withdrawal time for many physicians. As well, nearly all physicians have changed to split preparation, which is more in line with best practices. Physicians who have measured adenoma detection rates are also seeing improvements in cancer detection rates.xiv

Automated documentation and coding solutions have created a solid foundation for benchmarking programs at both ASCs by ensuring accurate and complete data capture and by streamlining the audit and reporting process. More comprehensive data capture is enabled through point of care and bedside documentation, and data is standardized for easier, faster queries. Data collection and interpretation become more consistent, and the audit process can be managed by a single person to eliminate discrepancies.

Vendor tools are also available in the market, specific to national benchmarking initiatives, to further enhance data integrity and streamline reporting. These tools integrate with procedure documentation and coding software to guide physicians through the process of capturing all required data elements. By organizing data into a specific format that can be transmitted directly to various registries, the collection process becomes more efficient and more accurate.

FWEC is using a specific GIQuIC tool that streamlines data collection and submission. For a midsize facility, automating data collection with the query tool can mean a time savings of up to 40 – 60 hours annually.xv

The information that is being collected by GACV and FWEC has positioned the organizations for external reporting requirements and for improved workflow and reporting processes. The information has been instrumental in earning GACV national recognition as a Best Performer in the 2010 AAAHC Colonoscopy Study for achieving the third-lowest average discharge time. xvi The organization also leverages benchmarking data for clinician credentialing, payer negotiations, peer review and performance evaluations, and to track medication side effects.


As the national regulatory landscape moves towards a pay-for-performance model, ASCs will have to instill solid benchmarking practices to stay relevant. Replacing manual processes with built-in decision-support tools enables accurate, complete data collection, ensuring compliance with national mandates and helping achieve quality metrics.
By guiding physicians through the documentation process at the point of care, procedure documentation software not only promotes evidence-based practices but also raises the bar on patient care and outcomes. Simply put, a foundation of advanced automation technology positions ASCs well for external reporting initiatives and provides them with a unique opportunity to deliver the highest standards of care.

Centers for Medicare and Medicaid Services. (2012, November 16). Ambulatory surgical center (ASC) payment [web page]. Retrieved from

ii Ambulatory Surgery Center Association. (2012). Outcomes monitoring project [web page]. Retrieved from

iii Medical Group Management Association. (2012). MGMA surveys reports [web page]. Retrieved from

iv GI Quality Improvement Consortium Ltd. (2012). GI quality improvement project description [web page]. Retrieved from

v © 2013 The National Quality Forum. All Rights Reser ved

vi A federal government website managed by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244

vii Wolters Kluwer Health. (2012). Fort Worth Endoscopy leverages the power of ProVation® software to track outcomes for improved quality [case study].

viii J. Brown, RN, Endoscopy Nurse Manager, Gastroenterology Associates of Central Virginia (interview, July 27, 2012)

ix Wolters Kluwer Health. (2012). Fort Worth Endoscopy leverages the power of ProVation® software to track outcomes for improved quality [case study].

x J. Brown, RN, Endoscopy Nurse Manager, Gastroenterology Associates of Central Virginia (interview, July 27, 2012)

xi Wolters Kluwer Health. (2012). Time, technolog y is right for ASCs to transition to a paperless environment [white paper]. Retrieved from Time,%20Technology%20is%20Right%20for%20ASCs%20to%20Transition%20to%20Paperless%20Environment.pdf

xii Wolters Kluwer Health. (2012). Gastroenterology Associates streamlines workflow with ProVation® MD, ProVation® MultiCaregiver [case study].

xiii Brown, J. and Meakem, T. (2012, October 25). Eliminating barriers to effective internal/external benchmarking. Presentation at the 19th Annual Ambulatory Surgery Centers Conference, Becker's Healthcare. Retrieved from p0215_The_Challenges Facing ASCs to_Capture Track and_ Report_ Meakem Brown.pdf

xiv Wolters Kluwer Health. (2012). Fort Worth Endoscopy leverages the power of ProVation® software to track outcomes for improved quality [case study].

xv Wolters Kluwer Health. (2012). Fort Worth Endoscopy leverages the power of ProVation® software to track outcomes for improved quality [case study].

xvi Wolters Kluwer Health. (2012). Gastroenterology Associates streamlines workflow with ProVation® MD, ProVation® MultiCaregiver [case study].