1. Establish a clear hierarchical review process. Before the staff implements a quality program, the surgery center board needs to set the direction for the program. Before you begin educating your staff, work with the board to look at The Joint Commission and AAAHC accreditation standards, state licensing standards and Medicare certification standards. “Look through those standards and make a list of everything they say must be included and reported,” Ms. Deno Thomas says. “Once you’ve done that, you need to know who’s going to be the most important [in enforcing those standards] and the second most important and the third most important.”
For example, your staff might report to your director of nursing, who will report to the executive committee, who will make a summary report to the board. To involve the entire staff in quality improvement, you don’t need to get every single nurse and physician and administrator and board member in one room. Instead, divide responsibilities among your staff members. Ask one to track cancellations on day of service, one to track medication errors and one to track patient falls. On a quarterly basis, ask each staff member to submit a report to the director of nursing, who will take the reports to the medical executive committee. Once the committee has reviewed each report, the medical director can report to the board on a summary of all the quality improvement reports instead of inundating the board with five unrelated reports.
This hierarchy works the opposite way as well, Ms. Deno Thomas says. “When the board makes recommendations based on that summary, those recommendations can trickle down through the executive committee, and changes can be addressed with each [responsible staff member].”
2. Require surgeons to take a 30-second pause before starting an incision. According to Ms. Deno Thomas, many ASCs assume wrong-site surgery can’t happen to them. Yet several years after accreditation bodies added a “time out” to check for potential surgery site mistakes, Ms. Deno Thomas says there has been little decrease in the rate of wrong-site surgery. “People are either going through the motions of checking the site, or they’re not even going through the motions,” she says. “People assume it’s not going to happen because they have a small facility, but they still need to be following that protocol.” The Joint Commission’s 2010 National Patient Safety Goals reduced the number of time-out checks to three: correct patient, correct site and correct procedure. Educate your nurses and surgeons that even a single wrong-site surgery can be a costly mistake for your ASC — and it only takes one slip-up to happen.
Ms. Deno Thomas says you may find your nurses are failing to follow protocol because they think physicians will object. “If nursing is afraid the doctors will get mad, you need to talk to the nurses and doctors about that,” she says. “The more people don’t listen, the more devalued the process becomes because people don’t take it seriously.”
3. Catch mistakes by being present in clinical areas. As an administrator, if you only visit the clinical area of your center every so often, your nurses and surgeons will learn to be on their best behavior when you’re in the room. Unfortunately, that doesn’t tell you very much about mistakes they make when you’re not around. Ms. Deno Thomas tells administrators, “Put your scrubs on every day and go back into the clinical area for two hours and help your staff turn over the room.” She says, “When you’re back there frequently enough that it’s not abnormal, you will begin to see what the staff normally does.” Once the staff becomes comfortable enough to drop the “best behavior” act, you’ll be able to see if they’re washing hands and following sanitization procedures. If you notice a particular nurse is failing to meet protocol, you can educate the nurses as a group or single that nurse out for individual coaching time.
This coaching will help your staff perform better when your center is surveyed. Ms. Deno Thomas says many ASCs rely on staff to achieve accreditation by being on their best behavior during the survey — but unfortunately it doesn’t always work like that. If your staff has developed bad habits, they may still make mistakes in the surveyor’s presence because the mistakes are routine. “The day of the big survey, everyone tries to jump back into the correct way of doing things, and they always slip up,” she says. “As the leader of the facility, you need to spend more time looking and listening from a patient and surveyor perspective and not pass it off because you’re busy with the budget.”
4. Deal with non-compliant staff members immediately. Don’t make the mistake of thinking a single non-compliant nurse or physician won’t hurt your center, Ms. Deno Thomas says. As soon as you notice a nurse or surgeon failing to meet quality standards, address the issue and offer education on why the practice is important. If you don’t, you will reinforce bad behavior and make the problem much more difficult to correct later on. Ms. Deno Thomas says she’s noticed a pattern in staff members’ reactions to mistakes: “The first time they mess up, they’re so frantic and are ready to quit their job, and they’re sure the patient is going to die,” she says. “The patient doesn’t die, and they’re relieved and vow never to make the mistake again. The second time, they feel some angst. The third time, they have a little bit of queasiness, and by the fourth time, that practice has become their standard of care.”
Ms. Deno Thomas says many ASCs fall down on very simple, basic standards such as handwashing and sanitization procedures. If you notice a problem, your reaction has to scale up with each additional violation or protest. You never want to have to fire a nurse or part ways with a physician, but you also shouldn’t let mistakes slide. “If you have an incorrigible physician, you would first have a very gentle discussion with the medical director,” she says. “Then you would send a letter reminding the physician of your policy and your displeasure at the incident. Then you start disciplinary action, where you remove privileges.” When you include a policy in your bylaws, stick with it or your staff will know failure to comply carries no negative repercussions.
