Anne Dean, RN, BSN, LRM, CEO and co-founder of The ADA Group, consultants for ambulatory development and regulatory compliance, shares seven quality improvement strategies based on the results of CMS surveys of ambulatory surgery centers.
1. Keep your physicians (safe) by making sure they practice within the policies, procedures and protocols established. Ms. Dean says this advice often surprises ASCs until she explains that "if you keep your physicians safe by making sure that they practice within the policies, procedures and protocols established by the center, then not only will they be safe, but so, then, will their patients, the organization and you," she says. "We had a center this last year who really struggled through their Medicare survey primarily because they elected not to follow the regulations or their policies."
A few of the corrective actions taken by this center to meet its deficiencies were the following:
- Physicians had to assess the patient in pre-op prior to their patient being taken back to the procedure area.
- Physicians had to sign, date and time their orders, H&Ps and consents prior to the patient being taken back to the procedure area.
- H&Ps had to be no older than 30 days (to include medical clearances).
- H&Ps had to be updated on the day of the procedure with changes, or no changes, noted, signed, dated and timed.
- Patients had to be assessed by their physician prior to discharge with a discharge note written, signed, dated and timed.
"The physicians were all instructed verbally and through a memo regarding these corrective actions," Ms. Dean says. "The nurses were informed by the administrative director, the operating room supervisor, the medical director and the licensed risk manager that under no circumstances was a patient to be taken into the OR/procedure room area until all of these [actions] were done, and no patient was to be discharged unless those related actions had been completed."
2. Get your board and medical advisory committee supporting you. On at least one occasion, Ms. Dean recalls going to an OR door and advising a surgeon — who was sitting on an instrument table in the OR talking to a tech — that he needed to come out to the pre-op to see his patient.
"We did a patient chart audit [in this center] on every chart every day for 45 days to ensure all these actions [mentioned in #1] were complete," she says. "That was a year ago. We have had, with six surgeons and as many anesthesiologists, only one deficiency where a physician left without completing his electronic discharge note/summary. The medical advisory committee and the board of directors got squarely behind their organization and are addressing this issue with the physician, but it was the authority that the MAC, board and administration gave to the nurses to make sure their physicians practiced within the parameters set forth by the organization that made the big difference.
"It is this attention to detail that has had this organization rally from two 'wrong side' surgeries two years ago to not even a 'near miss' this entire last year," Ms. Dean says.
3. Evaluate staff competency and continue rigorous staff development. Ms. Dean says she has received patient burn reports that concluded burns resulted from electrosurgery pad placement. "I would urge an in-depth in-service on electrosurgical and electrical, laser and radiology safety, fire and burns in the OR, and would evaluate staff competency in this area on a regular basis," she says.
She says such training is also necessary for prophylactic antibiotic therapy. "Medicare has published strict guidelines based upon the type of drug to be administered within one to two hours before the incision is made," Ms. Dean says. "We are seeing, still, some physicians ordering a prophylactic prescription for antibiotics to begin at home, and still have physicians ordering a 7-10 day post-operative regime."
4. Do your benchmarking now. Ms. Dean advises ASCs to perform their own benchmarking among their various physicians, even in the same practice, and take the results along with the Medicare guidelines to the MAC and board for their ruling and support. "I would not suggest this be one of those areas where we 'wait to see if we get cited,'" she says. "Money talks and this will, potentially, impact reimbursement."
5. Identify and correct physical plant risk; train staff to prevent falls. Ms. Dean says she urges her centers to assess their physical plant and environment identifying risk factors, which can include the following: frayed carpeting; unpainted parking spots or unidentified changes in pavement heights and curbs; and locks on wheels of chairs and stretchers. She also advises checking staff competencies on the use of locking wheels on chairs and stretchers, OR tables, using assistive devices and in ambulating patients and performing assessments.
"One of the issues we have uncovered — in this day of cranking nurses out of nursing school and from online education — is that many have not had the basic instruction regarding patient assessment and ambulation," she says. "At one center, I discovered the newer nurses had had no training in ambulating patients and assisting them should they start to fall. In another, [when] as I was inquiring as to why they were not having fall incidents and were not sending me incident reports, I uncovered that they had quite a few falls following surgery performed by a specific surgeon who used a specific anesthesia provider. When queried further, I discovered that this anesthesia provider administered a femoral block in the pre-op area, but that the patient was not advised of this until just prior to its happening. Thus, no walker or other assistive device was on hand."
To fix this problem, the center put its discharge assessment and planning program in place in the clinic prior to the day of the procedure. As a result, these patients no longer fell either in the center or at home.
Another issue surrounding falls lies in the sedation used, Ms. Dean says. One of the hazards of ambulatory surgery is that the drugs used wear off fast and oftentimes patients are believed to wake up "fully alert."
"But are they really?" Ms. Dean says. "There was a recent study by the Canadian Anesthesiology Society comparing the number of fatal car accidents to patients who had been administered propofol and who then went on to drive within 24 hours. The incidence of fatalities was alarmingly high. I know both from personal experience and from 30 years working with surgery centers that these patients feel perfectly awake and alert. Anesthesia and nursing staff think so, too. Many of them drive out of the parking lot and yet, I still have clients where the nurses balk at escorting the patients to their car citing staffing issues and the physicians not being willing to staff adequately to allow the nurses to leave to go to the parking lot with the patients."
6. Utilize a falls prevention program. "This simply has to be done," Ms. Dean says. "I know that CMS is looking at falls in the center, but they'll catch up to some of these issues. We had one center that sent patients home using cab service. The cab driver watched the patient climb his front steps and fall on the top stoop and lay there. After that incident, the cab company quit serving that center having thought it was a just a physician's 'clinic.' They stated they had no idea patients were having surgery and, thus, were not willing to accept the liability of transporting them with no care person in attendance.
"I have at least one client who discharges the patient directly from the procedure room with no stopover in recovery," she says. "Now CMS requires that stopover and a set of vital signs. Look at the liability — these patients get sedation and propofol. The patient identifier process should start with scheduling, go through admission, pre-op and into the OR."
7. Pause and P.A.W.S. (Please Ask Which Site/Side). Ms. Dean says preventing wrong site/side surgery starts with educating the reception staff to make sure the H&P, the consent and the schedule all match. "Find the error here," she says. "Correct it here, not in the OR, if at all. Do not permit your physicians to bypass checking out these documents with the patient and nursing staff in pre-op prior to taking the patient back to the OR."
She says it is not uncommon to see sentinel events where the wrong site or side was performed because of a discrepancy between the H&P, the consent and the surgeon's memory. "This means in pain management, too," Ms. Dean says. "Time outs in pain management procedures are critical, too, in avoiding wrong site/side procedures."
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