Sasso Consulting Founder and Surgery Center Coalition Co-Founder Marcy Sasso, CASC, discusses four major compliance issues for ambulatory surgery centers to avoid next year. 1. Lack of proper credentialing for existing surgeons. ASCs are always looking for new surgeons to bring cases, but allowing them to perform cases without the appropriate credentialing could spell disaster. Even surgeons who have performed cases at the center for years need to update their credentials before performing a new procedure at the ASC.
"An orthopedic surgeon, for example, that has privileges to do knees and shoulders can't all of a sudden decide to perform a carpal tunnel release if he isn't credentialed for it," says Ms. Sasso. "That doesn't mean they aren't trained to perform the surgery, but the center needs to credential them to do it. Sometimes administrators don't pay 100 percent attention to the procedures surgeons are doing, and the surveyor will check that."
Medical directors and directors of nursing are often responsible for credentialing, but with all the other responsibilities they have, credentialing can sometimes slip through the cracks. To resolve this issue, tie credentialing to the governing board for approval before new surgeons are able to perform procedures.
2. Missing paperwork for new surgeons. New surgeons that want to perform cases at the center must have proper credentials and privileges approved and documented in the minutes before regularly bringing cases. It can be difficult for centers that need increased volume to wait, but they must follow policy and procedures each step of the way.
"Each time you credential a new physician, specialty or procedure, your governing body needs to show oversight with reflection of that in the minutes," says Ms. Sasso. "You must show that your governing body has approved the new surgeons or procedures. Many times surgeons call the center and request to perform cases, but you have to wait until they have the correct and appropriate privileges approved."
ASCs often ask the surgeon's practice for their licensing and other paperwork, which may or may not be sent all at one time. Don't just take their word for it; check all the paperwork that arrives and confirm that it's current and meets policy requirements.
3. Pharmacy shortages and backorders. Surgery centers, along with providers across the country, have experienced drug shortages and backorders that could negatively impact their center. If ASCs aren't able to collect the required amount of materials or drugs on-hand because of national shortages, they need to document their backorder on the crash cart log and medication log to remain compliant.
"Contact the local authorities and ask whether they'd prefer you operate with an expired supply of drugs on hand or no extra drugs at all," says Ms. Sasso. "If they say to label the expired drug, do that. Others might ask you to substitute the drug with something else. Additionally, with syringes, you must label each syringe with the date and time if not for immediate use; medication drawn up in a syringe is only good for use within 60 minutes."
While it might be easier for anesthesiologists to draw up 10 syringes and have them ready to go, that isn't compliant and shouldn't be done, says Ms. Sasso.
4. Easy benchmarking projects. Benchmarking is required for any licensed ASC accreditation, and AAAHC and The Joint Commission require two benchmarking projects per year. ASC leaders can pick an easy study to achieve 100 percent, but surveyors want to see how the study helped the ASC improve a process.
"The surveyors want to know what you are doing," Sasso says. "You can take an internal study and do some external benchmarking. Find areas where you don't have the most efficient practice and you can study and implement a better process. If you aren't 100 percent at your goal or target range, you can do a QA project to make the center better."
Surgeons can benchmark against other surgeons in their own center to find variations and potentially standardize to the most efficient or cost-effective method. ASCs with management companies can use company data for benchmarks, and several groups including ASCA and Sasso Consulting are now rolling out benchmarking studies next year.
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