10 Critical Policies and Procedures for ASC Risk Management

Here are 10 of the most critical policies and procedures for reducing risk at an ASC according to Nancy Burden, MS, RN, CPAN, CPAP, director of BayCare Ambulatory Surgery in Largo, Fla., and Terri Brickey, RN, BSN, LHRM, CASC, administrator of Physicians Surgery Center in St. Petersburg, Fla.


1. Proactive actions and retroactive reporting. Any effective risk management program should include policies and processes that support proactive actions and retroactive incident reporting. "Many people think of risk management as an incident report, but your team has to understand that it's more than that," says Ms. Burden. "An effective plan has to include both proactive and reactive elements. It's really about being proactive and looking for ways to improve the service you provide."

Ms. Burden says ASCs need to use any incidents that may occur as an educational opportunity. "If you have an incident, such as a fall, you need to go the next step after reporting it and learn from it," she says. "You and your staff should investigate it fully and create proactive measures to lessen the chances of that incident happening again."

2. Patient consent that the patient understands and matches patient expectations. ASCs must develop policies that ensure patient consent forms are written in a language that can be understood by any patient and should use the patient consent process to check agreement between the ASC's understanding of a procedure and the patient's.

"It is the responsibility of the physician to discuss and obtain the patient's informed consent, but the paperwork of signing it often occurs in the center and is an opportunity to discern any confusion or disagreement," Ms. Burden says.

Ms. Burden says that the patient consent process can also provide a "stop" mechanism even before the day of surgery if any part of the surgery center's schedule, patient record or surgical plan do not match the patient's expectations.

"For example, if your center has booked a right-side surgery but the patient swears it's for the left, the patient consent process can detect and solve the disagreement," she says. "Everything needs to match — the patient chart, what was booked, what the patient understands. If it doesn't match, patient consent is a place where you stop everything if it's not correct and get it fixed."

3. Preoperative assessment that ensures proper patient population. ASCs also must have policies in place to ensure that only patients who are able to safely undergo procedures at an outpatient facility are treated in the facility. Nursing staff should evaluate each patient by phone or in person, checking for any indications that the patient might not be suited for an outpatient facility and report this information to the physician.

Ms. Brickey warns that centers should perform these assessments as early as possible so that the patient is not inconvenienced by arriving for a procedure and then learning that he or she is not a good candidate for surgery in the center.

"You must have a process in place for the proper evaluation of patients," says Ms. Brickey. "Proper assessment ensures that the nursing staff catches any risks before the day of surgery. We don't want to put these patients at risk, and we don't want to put our staff or the reputation of the center at risk either."

4. Ongoing patient identification. ASCs must ensure that patient identification occurs before any procedure and that it is an ongoing process throughout a patient's time at the ASC.

"Although it might seem obvious, if we get too quick in our ways, we could have a patient in the lobby answer to the wrong name and that could create a major problem if you don't have proper procedures to identify your patients," says Ms. Burden.
Ms. Burden suggests that ASC staff members have patients state their full name and date of birth, or two other identifying features as determined by your center's policy, as recommended by the Joint Commission.

"You should have the patient state the information, rather than asking 'Is this correct?'" says Ms. Burden. "Staff members must verify this information every time they see a new patient and patient identity should be verified before any procedures begin, before any medicine is given and before the start of an IV."

5. Mandated preoperative time outs. ASC leaders should require time outs to prevent wrong site, wrong procedure and wrong person surgery. This process, often referred to as the Joint Commission's Universal Protocol, should occur before all procedures, and the members of the surgical team should work to make certain that these protocols are observed by all members of the team.

"We follow the Joint Commission's standards for our time outs, which include surgical site marking by the physician, visualization of marking, verification of site, patient and procedure identification and verification of correct implant and equipment," says Ms. Brickey.

Although the use of time outs has become more widespread within recent years, the process can fall short if any member of the surgical team is not paying full attention.

"The problem area in this process is getting the full attention of everyone in the room," says Ms. Burden "For example, although a circulating nurse may carry out the time out, it does not ensure that everyone will pay close attention. [Someone] might be involved in other patient care issues and not fully engaged."

Ms. Brickey says that her center's policies help to ensure that attention is paid to this process by training the staff to work as a team to ensure compliance. "We encourage our surgery staff, such as the scrub tech and nurse, to act in concert to do the right thing for the patient," she says. "If a physician tries to move forward without a time out, the center's staff will stop him or her and work as a team to make sure that the proper procedure is followed."

6. Appropriate sterilization process and experienced sterilization staff. ASCs must not only have processes in place to ensure appropriate sterilization of equipment but they must also be careful to assign sterilization tasks to staff members who are experienced and reliable in the sterilization process.

"Sterilization is black and white: It's either sterile or it's not," says Ms. Burden. "You have to have processes to track everything you've sterilized, and you have people who know what they're doing. You need to be able to completely trust these people to do their job."

7. Proper medication management process. ASCs need to take steps to ensure that their medication supply is properly managed and that all medication is properly labeled and stored.

"Labeling is a big issue," Ms. Burden says. "Every solution on and off in the sterile field needs to be labeled unless you're drawing it up and dispensing it immediately. One particularly challenging area for this can be the top of the anesthesia cart." Anesthesia providers often titrate their medications for effect and can be changing syringes in the process. Having pre-made medication labels for their syringes can help identify medications and reduce risk.

Ms. Burden warns that staff members need to be particularly careful when pulling medications that have similar names, such as epinephrine and ephedrine. "When medications look and sound alike, we can avoid problems by ordering one medication under a different brand, such as ordering adrenaline instead of epinephrine, or by using tall man letters (which elongate the letters that are different in the spellings of the words) to highlight differences in the names," she says.

Ms. Burden also suggests that ASCs reduce risks associated with the accidental use of high-risk medications, such as heparin or insulin, by placing the medicine's packaging inside a plastic bag and then placing the bag in a container with a distinctive lid and label. "You want to make these medications take a bit of work to get in to," she says.

8. Discharge process that involves the patient's family and outcome tracking. Discharge instructions should be given in the presence of the patient's family and a follow-up phone call to the patient should occur the day after the patient is discharged, or earlier if warranted.

"Involving the family in the discharge instructions give everyone more confidence in being able to care for the patient during the home recovery. You should also make sure the patient and family has a phone number to call if they have any questions or concerns." says Ms. Brickey.

Ms. Brickey says that a follow-up call performed by nursing staff is an additional opportunity to find out what happens to the patient after the day of surgery. "If there are any red flags, we can address these right away," she says.

Ms. Brickey's center also sends infection and complication study surveys to all physicians each month so that the center is notified of any issues that occurred with patients after their discharge. "The physicians let us know if there were any complications and then we use that information to identify trends and take corrective measures, if necessary," says Ms. Brickey.

9. Procedures for responding to patient and employee complaints. ASCs should have policies that outline the proper response to both patient and employee complaints.

"You must empower your staff to respond and truly follow up with patient grievances," says Ms. Brickey "There's a reason the patients are reaching out, and their complaints can provide you with information to improve your care."

Ms. Brickey says that her staff is trained to deal with any complaints right away and to inform the patient that the complaint will be taken seriously. She says every complaint at her center is forwarded along to her, and she follows up with the patients, letting them know what will be done or if something will be changed at the center in response to the complaint.

Employee complaints should be taken as seriously as patient complaints, says Ms. Brickey. "Employees need to feel they work in a culture of safety. When they have grievances or feel something is not being done, they need to have trust in their risk management officer and their organization that it will be investigated and something will be done in response," she says.

10. Emergency preparedness plans and drills.
ASCs need to have an emergency preparedness plan for various types of emergencies in place, including fire or other evacuations, cardiac arrest and malignant hyperthermia, and the facility must perform drills of these plans on a regular basis.

"ASCs need to be prepared for both environmental and medical emergencies, and should perform drills for the most likely emergencies on a quarterly basis," says Ms. Burden. "These drills should include debriefings so that your staff can learn from them, making this component just as important as the drill."

Drills should account for every possible complication, says Ms. Burden. She says her staff performs a drill for malignant hypothermia in which the ice machine has run out of ice. "We really want our staff to be prepared for every possible situation," she says.

At a different ASC where Ms. Burden was previously employed, an emergency drill helped the ASC's leaders realize that the phone lines in the operating rooms were connected to long distance, which is required to call the malignant hypothermia crisis line that the center planned to use if an incident occurred.

"Drills identify your weaknesses as a center and can help you prepare for these incidents, so that when they do occur, your staff is ready and can respond in the best way possible," says Ms. Burden.

Contact Lindsey Dunn at This email address is being protected from spambots. You need JavaScript enabled to view it. .

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