Quality Improvement & Peer Review in the ASC
Building, running, and defending a QAPI program — through the eyes of the people who survey it.
8:00 a.m. – 5:15 p.m. EDT
8.0 education hours
Eight sessions
Live virtual + on-demand access
Why This Conference
The Surveyor’s Chair
The day closes with a full hour delivered from the other side of the table: the document request list in the order it is actually made, a QAPI tracer walked live from indicator to board minutes with the citation points marked, and the plan of correction that gets accepted next to the one that gets rejected. Questions at every stop, and an open floor before we close. You leave with the scored mock survey instrument to run it yourself.
A Full Hour on Infection Control
Infection control is the most frequently cited deficiency area in ASC surveys. It gets its own session: safe injection practices, high-level disinfection and endoscope reprocessing, sterilization monitoring and the implant load rule, and the §416.51(b) documentation that surveyors ask for first — proof of which nationally recognized guidelines you adopted, and who is qualified to direct the program.
Conference Agenda
Thursday, September 24, 2026 · 8:00 a.m. – 5:15 p.m. Eastern Daylight Time · Delivered live and virtually, with on-demand access to every recorded session afterward.
| Time | Session |
|---|---|
| 8:00 – 9:00 a.m. | Session 1The Regulatory Foundation for QAPIAccreditation requirements and the governing body’s non-delegable role in oversight. |
| 9:00 – 10:00 a.m. | Session 2Building the QAPI ProgramThe written plan, the committee, the meeting, and the discipline of closing the loop. |
| 10:00 – 10:15 a.m. | Morning Break |
| 10:15 – 11:15 a.m. | Session 3Quality Indicators, ASCQR & BenchmarkingSelecting indicators that mean something, and the federal measure set you already owe CMS. |
| 11:15 a.m. – 12:15 p.m. | Session 4Adverse Events, Reporting & Root Cause AnalysisWhat happens in the first twenty-four hours, and in the six weeks after. |
| 12:15 – 12:45 p.m. | Lunch Break |
| 12:45 – 1:45 p.m. | Session 5Infection Control Inside QAPI§416.51(b) — the integration surveyors test, and the practices they cite. |
| 1:45 – 2:45 p.m. | Session 6Peer Review: Structure, Process & Legal ProtectionBuilding a review process that is consistent, defensible, and actually protected. |
| 2:45 – 3:00 p.m. | Afternoon Break |
| 3:00 – 4:00 p.m. | Session 7From Data to Action: Credentialing, Privileging & the BoardWhere quality data becomes a privilege decision — and the loop finally closes. |
| 4:00 – 5:00 p.m. | Session 8 · CapstoneThe Surveyor’s PerspectiveHow your QAPI program gets surveyed — with questions taken throughout. |
| 5:00 – 5:15 p.m. | Closing and Wrap-Up — the day in review, five actions for Monday, and where to go next. Not included in the 8.0 education hours. |
Eight taught sessions · 8.0 education hours, exclusive of the scheduled breaks and the closing block.
The Sessions in Detail
The Regulatory Foundation for QAPI
Accreditation requirements and the governing body’s non-delegable role in oversight
The three layers of oversight every Medicare-participating ASC satisfies at once — federal Conditions for Coverage, deemed-status accreditation, and state licensure — and where the QAPI obligation actually lives in each. We read 42 CFR §416.43 and §416.41 word for word, identify the Appendix L tags surveyors cite them under, and establish the accountability chain the rest of the day assumes.
You will be able to:
- Recite what §416.43(a)–(e) requires and what it conspicuously does not require
- Distinguish state survey, deemed-status accreditation, and licensure — and know which one is looking at you
- Name the governing body’s five enumerated QAPI duties under §416.43(e) and the evidence each one produces
- Identify the current CMS-approved ASC accreditors and their deeming terms
Building the QAPI Program
The written plan, the committee, the meeting, and the discipline of closing the loop
Everything between the regulation and a working program. We build the written QAPI plan section by section, set the committee and reporting structure, define what counts as an incident in an ASC (it is not what a hospital counts), and run a full QAPI meeting from agenda through minutes. The hour ends on the single principle that decides most survey outcomes: every issue closes to a policy change, an education action, or a documented “no action indicated.”
You will be able to:
- Draft each required section of a written QAPI plan from a working template
- Build a QAPI meeting agenda and write minutes that survive document review
- Categorize any ASC incident and route it correctly
- Execute a six-step QI study end to end, with a worked example
- Scale the whole structure to a two-OR center without gutting it
Quality Indicators, ASCQR & Benchmarking
Selecting indicators that mean something, and the federal measure set you already owe CMS
Most ASC indicator sets fail for one of two reasons: they are generic, or they are statistically meaningless at ASC volumes. This hour fixes both. We write a complete indicator specification — numerator, denominator, source, owner, frequency, target — then map the ASC Quality Reporting Program measures you are already required to submit, so your internal dashboard and your CMS submission stop telling two different stories. We finish on the small-numbers problem: why a jump from one infection to two is not a trend, and what to do instead.
You will be able to:
- Apply the high-risk / high-volume / problem-prone framework to your own case mix
- Write a complete indicator specification on a blank form
- Name the ASCQR measures required for the current and upcoming payment determinations, and what non-reporting costs
- Tell a real trend from ordinary variation at ASC case volumes
- Source free, ASC-specific external benchmarks
Adverse Events, Reporting & Root Cause Analysis
§416.43(c) — what happens in the first twenty-four hours, and in the six weeks after
The adverse event spectrum from near miss to sentinel event, and what has to happen immediately: the patient, the report, the notifications, the evidence, and the assessment of what your state requires you to file and when. Then the part most programs skip — a root cause analysis worked all the way through on a real ASC event, from the first “why” to a corrective action specific enough to re-measure. We finish on what you say to the patient and family, which every accreditor addresses and most ASC policies do not.
You will be able to:
- Classify any event and trigger the correct internal, state and OSHA response
- Build the state-reportable event reference sheet your facility does not have
- Run a structured RCA that reaches a systemic cause, not a surface explanation
- Track and trend events in a way that survives a surveyor asking for the last twelve months
- Handle disclosure of an unanticipated outcome
Infection Control Inside QAPI
§416.51(b) — the integration surveyors test, and the practices they cite
Infection control is the most frequently cited deficiency area in ASC surveys, and the regulation is specific about why: the program must be directed by a designated, qualified professional, it must document the nationally recognized guidelines the facility considered, selected and implemented, and it must be an integral part of QAPI. This hour covers all three, then the practices that generate the citations — safe injection practices, high-level disinfection and flexible endoscope reprocessing, sterilization monitoring with implant quarantine, and post-operative surveillance that produces a rate you can defend.
You will be able to:
- Document the guideline adoption and infection preventionist qualification §416.51(b) requires
- Audit your own safe injection practices against the standard surveyors use
- Evaluate high-level disinfection and endoscope reprocessing, including drying and hang time
- Run sterilization monitoring correctly, including the implant load rule most centers miss
- Conduct an infection control risk assessment that actually drives a QAPI priority
Peer Review: Structure, Process & Legal Protection
Building a review process that is consistent, defensible, and actually protected
CMS never uses the phrase “peer review” — your accreditor does, and so does your malpractice carrier. We build the committee, the case selection criteria, and the rating scale with anchored examples so two reviewers reach the same conclusion on the same case. Then the legal half, in one place: what HCQIA actually protects (people, not records) and the presumption that shifts the burden to the physician challenging you, what state statutes add, what the Patient Safety and Quality Improvement Act offers in states with weak protection, and exactly where privilege gets waived.
You will be able to:
- Separate peer review from QI review, and know why the distinction is legal as well as operational
- Set defensible case selection criteria and apply a four-level rating scale to real cases
- State what HCQIA immunity requires — including the rebuttable presumption
- Identify when a PSO relationship is worth pursuing and what it does and does not cover
- Keep the protected file, the committee minutes and the summary that crosses to the board correctly separated
From Data to Action: Credentialing, Privileging & the Board
Where quality data becomes a privilege decision — and the loop finally closes
Quality data that never reaches a credentialing decision is a program running in a circle. This hour connects them: what §416.45 requires for medical staff qualification and periodic reappraisal, what belongs in a credential file, how procedure-specific privilege delineation prevents the most common privileging citation, and how ongoing performance data feeds reappointment — in whichever language your accreditor uses for it. We cover corrective action from counseling through revocation, the National Practitioner Data Bank threshold and deadline, and the governing body minute language that proves the loop closed.
You will be able to:
- Cite the right regulation for privileging — and stop citing the wrong one
- Build a credential file and privilege delineation that survive file review
- Translate ongoing performance review into your accreditor’s language, whichever one you use
- Determine whether an action is NPDB-reportable and when the report is due
- Write governing body minutes that document a decision rather than a discussion
The Surveyor’s Perspective
How your QAPI program gets surveyed — with questions taken throughout
Seven hours have been about building the program. This one is about being on the receiving end of one, delivered from the surveyor’s chair — and structured so you can interrupt. The opening conference and what the team is deciding in the first ten minutes. The document request list, in the order it is actually made. The QAPI tracer, walked live from a single indicator through the data source, the collection tool, the committee minutes, the board minutes and back to re-measurement, stopping at each point where a citation drops. What gets cited and at what level, one Immediate Jeopardy worked end to end, and the plan of correction that gets accepted next to the one that gets rejected. Questions at every breakpoint, and an open floor before we close.
You will be able to:
- Anticipate the QAPI document request and produce every item inside ten minutes
- Follow a tracer through your own program and find the break before a surveyor does
- Distinguish standard-level from condition-level findings, and both from Immediate Jeopardy — and know the clock on each
- Write a plan of correction containing every element CMS requires
- Run a scored internal mock survey of your QAPI program and act on the result
Conference Chair & Lead Faculty
John Goehle has spent his career inside ambulatory surgery centers — running them, consulting for them, and teaching the people who lead them. He is the author of the ASC industry’s long-running operations references and the host of The ASC Podcast with John Goehle, the longest-running podcast in the ASC industry. This conference reflects how he actually works with centers: read the regulation as written, build the document that satisfies it, and then look at the result the way a surveyor will.
Reserve your seat at the most comprehensive QAPI conference in the industry
$399.99
per registration
September 24, 2026 · 8:00 a.m. – 5:15 p.m. EDT · 8.0 education hours · Live virtual, with on-demand access to every session afterward.
Questions? Email info@asc-central.com.