1. What do you see as the top safety challenges facing ASCs today?
Michael Kulczycki: First, infection prevention, despite the fact that ASCs, historically, have had a very low infection rate. I think the last -report from the ASC Association’s benchmarking has infection rates well under 1 percent. I think occurrences recently in Nevada and New York are raising a lot of visibility on that, and ASCs are going to see, potentially, some increased regulatory pressure about some very specific practices including guidelines around the use of multi-dose medications.
Longer-term, I think you’re looking at the use of best practices regarding surgical infections — things like no hair-clipping, antibiotic use before surgery and then suspension of antibiotic medications are also going to get a lot more attention. It’s likely CMS will adopt some of those best practices as part of its future requirements for reimbursement (for more, see Preparing for Quality Reporting in 2009). A recent preliminary study showed that more than half of the organizations were already doing it but the industry will have to come a lot farther, a lot faster.
Also, the case in Florida just reminds people of the need to stay on top of malignant hyperthermia. The Malignant Hyperthermia Association of the United States is rich in resources about basic reminders of what you need to have on hand and just a reminder that this can affect everybody.
2. What makes/continues to make these challenges so difficult?
MK: The one advantage of an ASC over a hospital is if they recognize a change in practice, they can much more quickly implement it. The downside of that is, as opposed to a hospital where they can more simply mandate it for the surgeons, changing surgeon behavior and practice is more difficult in an ASC setting, particularly when some of the surgeons might be the principal owners of the overall organization. It’s the nature of behavior.
I’ll use an example of our current Universal Protocol. That protocol has been around since 2003, it’s been endorsed by many of the physician specialty societies, and we here, at the Joint Commission, continue to see rates of 20 to 25 percent non-compliance. Behavior is hard to change.
3. Can you offer some quick tips for what ASCs should be doing (that perhaps they aren’t already) to keep these challenges from becoming problems in their centers?
MK: In terms of infection prevention, CDC recently updated some very specific resources about infection prevention (www.cdc.gov/ncidod/dhqp/gl_isolation.html), particularly with needle use, and I think ASCs should obtain that resource and make sure everybody’s well-versed in it. My other suggestion is to take advantage of the Association for Professionals in Infection Control and Epidemiology, the society for prevention of infection, and use it as a resource. The Association of periOperative Registered Nurses is another good resource. Finally, the ASC Association is also engaged with states like Nevada and others to help encourage improvements.
I also encourage ASCs to stay very tuned to the regulatory agencies in their states. In Nevada, they’ve already talked about some state-specific things; they’re talking about it in New York as well. ASCs in other states should pay attention to what is happening in these states. As it is with wrong-site surgery, it’s the issue of practices, such as those dealing with multi-dose vials or using multi-dose medications that are really designed for single-dose. I think that practice is much more widespread than people realize and, again, it’s a matter of changing behavior.
4. What does the Joint Commission see as major future challenges for ASCs in the next year, five years and 10 years?
MK: One area I would suggest ASCs look closely at is sleep apnea. In 2008, the Joint Commission looked very hard at recommending a National Patient Safety Goal in this area. We’re likely to re-look at it for 2010. The issue here is there is so much undiagnosed sleep apnea and it has so much impact on unintended and unanticipated outcomes from use of certain anesthetic agents that it’s very hard to predict, so this is an area that I think organizations will need to pay more attention to.
Another area for ASCs is patient falls. The Joint Commission does not currently make applicable to the ambulatory setting a current patient safety goal as it has for some institutional settings on patient falls. As I watched the field, I’ve seen a lot more attention in the ASC environment to that issue. I’m aware of a lot more organizations that have implemented some steps, so that’s another area that we likely may look at: making the current goal in terms of falls, adapting it to the ambulatory environment and then making it potentially applicable in the future.
A third challenge is for ASCs to continue to improve their compliance with Universal Protocol for prevention of wrong-site surgery. The Joint Commission just released revisions to this protocol for 2009 (www.jointcommission.org/PatientSafety/UniversalProtocol), including suggestions from the surgery field as captured during the Wrong-Site Summit in 2007.
The final thing in this area is, as part of the Joint Commission’s own improvement efforts, we’re just now starting to launch what we are calling a robust process improvement. We’re going to take a look across the quality spectrum and start to train some staff internally and take advantage of some quality mechanisms that are much more widely used in the commercial environment, and in a limited fashion in the healthcare environment. These tools include such approaches as Lean, Six Sigma and accelerated-change processes. We’re going to train Joint Commission staff and to generate changes to our own internal processes so we can better serve our current customers and, more importantly, we’re going to use those same processes and focus on how can we help healthcare organizations become what is known as high-reliability organizations, much like airlines, nuclear submarines and nuclear reactors.
To do that, we’re going to be launching, in 2009, a new center that’s going to focus on trying to pilot test these quality mechanisms with some healthcare organizations, initially at the hospital level but ultimately cascading those practices down as appropriate to other settings including ambulatory.
5. What are some effective means you have seen ASCs use to publicize their high level of quality and commitment to safety to patients, physicians and even payors?
MK: More and more organizations are promoting their accreditation status, and the Joint Commission’s "gold seal of approval" is well-recognized.
I was recently at a surgery center in West Des Moines (Iowa). It was using a number of resources available on our Web site under our Speak Up initiatives program (www.jointcommission.org/PatientSafety/SpeakUp), including how to prevent surgical mistakes, how to prevent infection and how to prevent medication mistakes. Organizations can use these free resources in a downloadable brochure format and distribute those to their patients.
Increasingly, you see ASCs participate in national time-out day, a joint program between AORN and the Joint Commission.
I’ve also seen organizations take things like wrong-site surgery and elements of our Universal Protocol and create internal staff games, contests and fairs to have staff become fully aware of it, and I’ve seen some these even spill over to the patient environment.
Note: Learn more about the Joint Commission’s Ambulatory Care Accreditation Program.
