John J. Goehle, COO of Ambulatory Healthcare Strategies in Rochester and Albany, N.Y., is author of "The Survey Guide for ASCs - A Guide to the CMS Conditions for Coverage & Interpretive Guidelines for Ambulatory Surgery Centers." He identifies eight problem areas for ambulatory surgery centers in a Medicare survey.
1. Obtaining advance directives. Most ASC staff members probably already know they are now required to ask patients about advance directives prior to the day of surgery, but they may not know what to do if the patient actually wants to make a directive. "It is not enough simply to ask patients on a form what they want to do," Mr. Goehle says. If the patient checks the 'yes' box, staff members need to ask what the directive is. It is enough to get a verbal directive from the patient, something like, "If anything happens to me, I want my husband to decide what the doctors should do." Site surveyors will look for this directive in the patient's medical record.
2. Board's involvement in ASC operations. All too often, ASC boards are detached from day-to-day operations at the center. Medicare standards require they have an active role in overseeing all aspects of operations, including quality improvement and infection control processes. Board members should meet on a regular basis — at least quarterly — and document their meetings. "Some boards don't even meet, while others meet but don't document it," Mr. Goehle says. "And even when there is documentation, it is usually much too brief." Board minutes should be at least a page long for a small center and three or more pages long for a larger center.
3. Adherence to infection control manual. ASCs must have an infection control manual. They can base it on a variety of sources, such as recommendations from the CDC, APIC or AORN. But buying ready-made manuals instead of compiling them personally alerts surveyors that ASC staff may not know what is in the manual, much less follow the requirements it spells out, Mr. Goehle says.
In these cases, "surveyors are more likely to select some standards in your manual and check to see whether you are following them," he says. A ready-made manual may obligate the center to take steps beyond what Medicare or ASC accreditors require. "The danger is they would be required to do something but never bothered to read about it," he says.
4. Meeting quality benchmarks. ASCs will soon have to meet national quality standards that were recently published. CMS has indicated it will be monitoring ASC oversight of eight measures, including patient burn, patient fall, wrong site, hospital transfer or admission, timing of prophylactic intravenous antibiotics, appropriate method of hair removal, selection of prophylactic antibiotic and surgical site infection rate. This involves not just comparing the ASC's outcomes to a national benchmark, but also doing something about it. "If you have a high infection rate, examine why it is high and what process could reduce the rate," Mr. Goehle says.
5. Overseeing contracted workers. Surgery centers need to monitor maintenance contracts, such as for outside cleaning services, to ensure they are in accordance with rules and regulations. The cleaning service needs to follow infection control guidelines. Surveyors may ask whether anyone is watching the service. Someone on-staff should be coming in when the cleaning crew is at the ASC and checking up on them. If no one comes in, the ASC should be using surveillance cameras.
The same applies to maintenance of equipment by outside vendors. "Make sure they are doing the maintenance," Mr. Goehle says. "Are they following the manufacturer's requirements?" Also, when monitoring reports are made, what is being done to follow up?
6. Conducting peer review. CMS requires physicians to review each other as part of the ASC recredentialing process, but this is often overlooked. Mr. Goehle recommends quarterly reviews so that any problems can be discovered early on, but they could also be semiannual or even annual. The process involves a colleague in the same specialty reviewing a few charts and making a report that would be put into the physician's recredentialing file. Infections, complications, complaints and grievances involving the physician would also go into that file.
7. Meeting QI standards. Frequently, the quality improvement process at a surgery center does not include enough people and is not truly evidence-based. "Sometimes there is only one nurse involved in the QI process, but actually it should include representatives from all departments at the center," Mr. Goehle says. He says this is less of a concern at smaller ASCs, where staff split their time among several tasks.
In addition, the QI process should do more than just react to a particular incident at the center. QI also involves having an evidence-based protocol examining quality data over time. "For example, people at the ASC should be looking at their current infection rates compared with a year ago," he says.
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