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10 Critical ASC Accreditation and Patient Safety Challenges and Best Practices to Overcome Them

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The accreditation process can be challenging for ASCs, but it remains one of the best ways for facilities to demonstrate their commitment to patient safety. Here, leaders from three leading ASC-accrediting organizations discuss the 10 of the biggest challenges in patient safety and accreditation and provide best practices for overcoming them.



1. Patient identification and universal protocol documentation. One critical challenge for ASCs is adherence to patient safety practices such as proper patient identification practices and performance of pre-procedure verification for every case performed. Accrediting bodies typically require ASCs to confirm the identity of patients before any medications are administered or procedures performed. Accrediting bodies also require ASCs to a checklist of items to ensure proper site, person and procedure before every procedure.

Beverly Robins, field director for the ambulatory care accreditation program at The Joint Commission, says that although compliance in these two areas by ASCs has greatly improved over the past several years, proper documentation of compliance is one of the biggest challenges in the accreditation process. "ASCs are carrying out these processes, but they fail to document it in the patient chart," she says. "[The Joint Commission] is looking for a simple record that identification and universal protocol took place — the expectation is that the completed components of the universal protocol and time out are clearly documented."

Michael Kulczycki, executive director for The Joint Commission's ambulatory care accreditation program, suggests that ASCs add a checkbox in the patient record form that can simply be checked when identification and universal protocol have been performed. Adjacent to this checkbox, the organization could list the components of the time out and universal protocol, he says.

Ms. Robins also recommends that ASCs involve patients in this process. "If we are asking patients a series of questions about their identity in a short period of time without acknowledging why we are doing this, it can be confusing to patients," she says. "Patients need to be involved so they understand that all of this effort directly relates to patient safety."

Michon Villanueva, assistant director of accreditation services for the Accreditation Association for Ambulatory Healthcare, agrees that surgeons performing the procedures need to involve patient in verifying and marking the site for surgery.

"The World Health Organization surgical checklist covers what should happen prior to surgery and really is an invaluable tool for surgery centers," says Ms. Villanueva.

Joint Commission surveyors report that some ASCs are involving patients by placing information on identification and universal protocol compliance, often in the form of a large poster, in each patient care area and encouraging patients to ask questions about the process.

2. Adherence to CMS's new Conditions for Coverage regarding infection control. Beginning on May 18, Medicare-certified ASCs across the country were required to comply with CMS's new and more stringent Conditions for Coverage for infection control.

"Infection control requirements are becoming more stringent due to recent incidents, such as the Nevada ASC incident [during which poor infection control practices led to a hepatitis C scare]," says Susan Lautner, RN, BSN, MSHL, an accreditation specialist for quality and patient safety at the Healthcare Facilities Accreditation Program. "You would think these procedures would already be in place in all ASCs, but doing the right thing sometimes cost more money. This is clearly a critical issue, which is why we see CMS jumping on it."

Accrediting bodies are currently revising their guidelines to include the new Conditions for Coverage. The Joint Commission, for example, is currently pilot testing the survey of standards and survey procedures regarding infection prevention and control in order to ensure that all components of the CMS infection control worksheet are incorporated into the survey process. In addition, The Joint Commission has performed a cross-walk of the CMS requirements to the elements of performance in its standards manual. The AAAHC is adding a new core chapter to its 2010 Handbook devoted to infection control and safety to help ASCs better handle these areas, and HFAP is revising its standards as well.

"Every ASC needs to pay attention to the infection control worksheet and use it to be prepared for these changes," says Mr. Kulczycki.

3. Accurate current medication lists. Another practice typically required for accreditation and related to patient safety that ASCs may find challenging is obtaining accurate lists of all medications that each patient is currently taking.

"All healthcare organizations struggle with this," says Ms. Robins. "Often the lists provided by the patient can be incomplete or inaccurate. [Patients] know they are on a blue or pink pill but aren't sure of the name or dose, and they don't always give the correct information to the ASC."

Ms. Robins says that ASCs typically ask patients for a list of medications during the pre-operative phone call, where they are at home with any medications they are taking close by, or through calls to the patients' referring or primary care providers. The Joint Commission is currently formulating new goals for member organizations regarding medication reconciliation, but, for the time being, she recommends that ASCs request that patients bring in the original packaging for all medications they are currently taking on their procedure day. Having all medications on-site in original packaging greatly reduces the likelihood of inaccurate medication information being passed on to the anesthesiologist and surgeon.

4. Ensuring current patient history and physicals.
Meeting guidelines set by accrediting bodies regarding the timing of patients' most recent history and physical is another area that ASCs may find challenging. The Joint Commission, for example, requires that all patients who undergo a procedure at an ASC must have on record a completed physical and history that occurred no more than 30 days before the date of the procedure. In addition, this document must be updated on the day of the procedure to assure that no changes have occurred since the examination was completed.

ASC staff is responsible for ensuring that a current physical and history, as defined by its accrediting organization, is on file for each patient, and sometimes ASCs fail to do this, says Ms. Robins. "ASCs need to take a harder stance on this by canceling procedures if a current physical and history cannot be obtained from the referring physician."

5. Tracking post-operative complications and infections.
It is critical that ASCs appropriately track post-operative complications and infections, especially those who rely solely on primary care providers and referring physicians to report incidents back to the ASC.

According to Marsha Wallander, RN, assistant director of accreditation services for AAAHC, one of the biggest challenges to infection assessment in ASCs is the limited amount of time that the patient is present. "In hospitals, nurses and staff members are providing care for the patient for greater than 24 hours and can assess subtle changes in a patient's assessment," she says. "In ASCs, the goal is to get a patient to a safe post-operative assessment status and allow recovery at home.  However, infections may not be evident for days post-discharge."

As a result, Ms. Wallander says ASCs may struggle to keep track of patients and make sure that they care taking proper care of themselves after surgery. "Some centers have sent detailed letters regarding care or e-mails prior to surgery about proper care. Others have worked with the office of the referring physician to keep in contact about a patient's post-operative condition. I think with the new Conditions for Coverage we will see surgery centers with innovative ideas to keep patients in the loop when it comes to their recovery care and we will see great and creative ways to monitor patients after surgery and post-discharge."

Ms. Robins says that although it is sometimes difficult to determine if the infection occurred as a result of the ASC, the ASC is still responsible for investigating any incidents. Starting in 2010, The Joint Commission will require ASCs to collect this data for 30 days after all procedures and one-year after any procedures involving implantable devices.

Ms. Robins recommends that facilities request complication and infection information via phone calls directly to patients, so that the ASCs are not totally reliant of physicians for this information.

"Generally, ASCs rely on the surgeon and his or her staff to voluntarily report any [complication and infection] information back to the ASC. However, the ASC is ultimately responsible for tracking patient infections, and if this doesn't occur, the ASC infection control and prevention data may be inaccurate, and they may miss required state and federal reporting requirements," says Ms. Robins.

According to Ms. Lautner, data on complications should be examined monthly within each facility and reported quarterly to an organization that tracks benchmarking data, such as the ASC Quality Collaboration, which is endorsed by the National Quality Forum. The ASC Quality Collaboration currently tracks data on a number of complications including patient falls, patient burns, hospital transfers and admissions after surgery and wrong site, wrong surgery and wrong patient measures. For HFAP-accredited organizations, reporting to the ASC Quality Collaboration is currently voluntarily, but Ms. Laupner expects it to eventually become mandatory.

6. Continually evaluating and improving performance. In addition to tracking post-operative complications and infections, ASCs should continually track quality measures, such as clinical outcomes and patient satisfaction, and use that data to set performance improvement goals.

"ASCs have to document that they are continually improving," says Monda Shaver, RN, BSN, MSHM, director of educational services for HFAP. "They should collect and track patient outcome and patient satisfaction measures and should continually implement processes to improve on these measures."

7. Requiring true peer reviews. ASCs are typically required by their accrediting bodies to mandate peer review of all physicians credentialed at their facility. However, this can be challenging to smaller and single-proprietor ASCs.

"Typically what peer review means is that another surgeon reviews a select number of a surgeon's cases," says Ms. Robins. "However, in ASCs where there is only one physician in a specialty, we sometimes run into cases where the physician reviews his or her self."

Ms. Robins says that ASCs must ensure that each physician who is credentialed at the ASC has peer review comments on file by another physician. She suggests that physicians who do not have peers at the ASC approach colleagues at the hospital, or small ASCs pair with other ASCs with a similar specialty mix for reviews.

8. Transitioning care between providers. Although a smooth transition of care between the ASC and other providers is not commonly surveyed by accrediting organizations, this may be something that accrediting bodies move toward surveying in the future.

"Going forward, we will be starting to look at communication between providers and the transition of care," says Ms. Lautner. "[HFAP] is currently emphasizing this for hospitals but we eventually want to carry that same thread of continuity of care to all facilities."

According to Ms. Shaver, ASCs should anticipate requirements regarding the communication of patient discharges and procedure outcomes to other providers. "There should be some kind of confirmation process that the referring provider has received accurate information on whatever was performed at the ASC and a full report of that procedure's outcomes," she says.

9. Maintain compliance and proper training. One of the best ways to keep on top of risk management and accreditation requirements is for the governing body of the ASC to maintain its awareness of these responsibilities, according to Ms. Wallander.

"ASC should make sure that leadership and directors of nursing and medical staff are educated and supportive of the standards," she says. "If they are well trained, then they can make sure that staff members are in compliance and aware of the ASC's policies and procedures, such as surgical timeouts."

Ms. Wallander also notes that communication is key in all areas of operation, from organizing the materials that should go to the patient prior to surgery to training materials to written policies and procedures.

10. Use tools available for patient safety. According to Ms. Wallander, most ASCs have developed useful patient safety policies that work best for their particular patient population. As mentioned earlier, the WHO provides a surgical checklist that surgeons and staff members can use to confirm the surgery to be performed. Additionally, Ms. Wallander notes that the accreditation body will also have tools available for ASCs to use and to help them develop procedures that best fit the ASC.

Ms. Wallander also advises ASCs to review their policies and procedures annually and as needed, such as when a new piece of equipment is introduced, to make sure that they are comprehensive and up-to-date.

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