Clinical Statistics Surgery Centers Should Look at Every Month

The following article is written by Kathleen Bernicky, director of clinical operations, Ann O'Neill, director of clinical operations, and Carla Shehata, director of clinical operations, for Regent Surgical Health.


Per the Ambulatory Surgery Center Association (ASCA) news this month, CMS is now proposing that ASCs, like hospitals, will have to report quality measures or receive payment reductions starting in 2014. Regent Surgical Health's model for quality assurance has always included measuring clinical indicators against industry benchmarks, as well as measuring for sustained improvement when addressing internal clinical challenges. Clinical leaders ought not to shy away from collecting and analyzing clinical statistics. There is great value in the numbers.

 

It is all about quality. Tracking clinical statistics on a monthly basis helps administrators, directors of nursing and quality assurance/performance improvement committees to keep a finger on the pulse of patient care. Clinical statistics help to identify strengths and weaknesses in patient safety, utilization of best practices, cost efficiency and regulatory compliance. Statistics are collected monthly, then collated and reported quarterly by the director of nursing to the ASC's QAPI Committee and to Regent. Regent is also requiring affiliated ASCs to participate in the ASC Association's Outcomes Monitoring Project.

 

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Overlapping with operational statistics, from the clinical side Regent centers also measure patient, physician, and staff satisfaction as well as costs per case. Monitoring these critical areas from a clinical perspective can give us early indications for needed changes in behavior or improved stewardship of clinical resources respectively.


The following table compares the combined internal Regent and external ASCA indicator lists to the proposed CMS mandated indicators.

 

Indicators

Regent Surgical Health
Monthly/Quarterly Clinical

Proposed Reportable CMS

Prophylactic Intravenous Antibiotic Timing

x

x

Appropriate Method of Hair Removal (i.e. clippers)

x

 

Surgical Site Infection Rate

x

x

Hospital Transfer/Admission Rate

x

x

Unexpected Complications Rate

x

 

Death in ASC or within 48 hrs Rate

x

 

Return to Surgery within 48 hrs Rate

x

 

Patient Burn Rate

x

x

Medical Device Failure Rate

x

 

Unintentional Retained Foreign Body Rate

x

 

Patient Fall Rate

x

x

Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant Rate

x

x

Medication Errors Rate

x

 

Volume of Occurrence Reports (not benchmarked)

x

 

Sentinel Events (appropriate follow-up)

x

 

Selection of Prophylactic Antibiotic First or Second Generation Cephalosporin Rate

 

x

Patient Satisfaction

x

 

Physician Satisfaction

x

 

Employee Satisfaction

x

 

Cost Per Case Supplies

x

 

Cost Per Case Labor

x

 

Intensive Clinical Review Scores % Compliance

x

 

 

Objective measurement is the only way to evaluate clinical performance of an organization's people and processes. Comparing to industry benchmarks helps us to set internal goals for improvement. Measuring against past performance gives an indication of whether or not we have sustained improvement. Addressing the concerns raised by the statistics helps to maintain quality. For all these reasons, successful clinical leaders embrace statistics.

 

Learn more about Regent Surgical Health.

 

More Articles Featuring Regent Surgical Health:

ICD-10/ 5010 Implementation: Are You Ready?

Understanding Surgery Center Exit Strategies

Return on Investment on Electronic Health Records

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