Thirteen of Baptist Health’s ASCs have earned recognition from The Leapfrog Group, a designation that signals strong performance on patient safety and quality measures at a time when ASCs are caring for increasingly complex patients.
Mandy Gerlach, COO of Coral Gables, Fla.-based Baptist Health South Florida’s Outpatient Services, joined Becker’s to discuss how the ASC division drives safety on a day-to-day basis.
Editor’s note: This interview was edited lightly for clarity and length
Question: How does your ASC or your ASC team approach quality and patient safety on an ongoing basis? What role do processes, consistency, and culture play?
Mandy Gerlach: For us, our commitment to quality and patient safety really starts at the top, from senior leadership down. All of our staff, from frontline employees to senior leadership, are evaluated on quality measures and KPIs related to patient safety. We have a very engaged medical staff who are committed to patient safety, along with risk management, patient safety educators, and infection control.
We standardize our practices to align with evidence-based care. One thing that works well from a process and culture perspective is that we consistently review all quality metrics and data via site scorecards. Those roll up to the Ambulatory Surgery division and help us implement performance improvement and action plans as needed. We operate as a high-reliability organization, and patient safety is part of our culture every day.
Every staff member has at least one quality metric included in their annual evaluation. They review these monthly. Most staff also have at least one operational or performance improvement metric. In addition, competency-based components are part of the evaluation as well.
Additionally, we actively review patient feedback through surveys and other communications. That information rolls up to our governing bodies, so leadership sees it and can make decisions based on patient experiences.
Q: Which safety practice are you most proud of that patients might not notice?
MG: This year, we implemented a fall prevention program. Usually, in the ASC setting, you don’t think of many falls because patients are ambulatory, but they do happen. All our sites have ways to flag patients at higher risk.
One initiative, based on staff feedback, is a board at each site showing the number of days without a patient fall. Some sites have more than 600 days. It’s a visual way for staff to see how their work impacts patient safety and take ownership of the performance improvement initiatives.
Q: What’s the single biggest improvement your team made in the last year?
MG: We standardized the electronic medical record for the GI service line. Previously, we had three different EMRs across our GI ambulatory surgery centers. Standardizing allowed us to create a GI collaborative — a multidisciplinary team including physicians, educators, and leadership — to standardize documentation, best practices and evidence-based guidelines.
It created better alignment across 14 centers, both for the employee experience and the ability to track quality metrics consistently.
