Overview of Quality Reporting in Surgery Centers: Q&A With Donna Slosburg of the ASC Quality Collaboration

In early July, CMS released the 2012 hospital outpatient/ambulatory surgery proposed rule (CMS 1525P). This includes the agency's proposal for establishment of a requirement for ASC quality reporting. Donna Slosburg, BSN, LHRM, CASC, executive director of the ASC Quality Collaboration, discusses the proposal, the quality measures included in it and what ASCs need to do with this information.


Q: What should surgery centers do with the proposed rule, particularly the components affecting ASC quality?


Donna Slosburg: They should begin by reviewing the proposed rule (which can be viewed by clicking here (pdf)), specifically Section K — "Proposed ASC Quality Reporting Program" (located on p. 42336). ASCs should familiarize themselves with what has been proposed.


It's worth noting that all six of the ASC Quality Collaboration's National Quality Forum-endorsed measures are proposed for inclusion in the measure set for ASC reporting. They are as follows:

  • Patient burn
  • Prophylactic IV antibiotic timing
  • Patient fall in the ASC
  • Wrong site, side, patient, procedure or implant
  • Hospital transfer/admission
  • Appropriate surgical site hair removal


The measures developed by the ASCQC include both outcome measures and process measures. An outcome measure assesses patients for a specific result of healthcare intervention. A process measure evaluates a particular aspect of the care that is delivered to the patient.


Q: Which are outcome measures and which are process measures?


DS: Four are outcome measures. These measures are patient falls, patient burns, hospital transfer/admission and wrong site/wrong side/wrong patient/wrong procedure/wrong implant. The fifth and sixth measures are infection control process measures which evaluate the timing of the administration of intravenous antibiotics for prophylaxis of surgical site infection and appropriate surgical site hair removal.


Q: Should surgery centers wait until CMS implements the final rule to start using these measures?

DS: You may choose to wait until CMS finalizes its policies regarding the ASC quality reporting system. However, by implementing these measures now, ASCs have the opportunity to gain valuable experience and possibly improve their performance before the measures are collected and publicly reported.


Q: Can you discuss some of the key things ASCs should know about each of the ASCQC's quality measures, starting with patient burn?


DS: The patient burn measure addresses ASC admissions experiencing a burn prior to discharge. There are numerous case reports in the literature regarding patient burns in the surgical and procedural setting. The literature on burns suggests that electrosurgical burns are most common.


It is critical for ASCs to recognize the diversity of mechanisms by which a patient could sustain an unintentional burn in the ASC setting. The definition of "burn" is broad, encompassing all six recognized means by which a burn can occur — scalds, contact, fire, chemical, electrical or radiation.


The best way to prevent burns from inadvertent cautery (ESU) activation is to always place unused electrosurgical electrodes in well-insulated safety holsters and not on the patient or drapes. Be hyper aware of facial cases when oxygen and the cautery are being used.


A reasonable goal would be no patient burns.


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Q: Prophylactic IV antibiotic timing?

DS: The prophylactic IV antibiotic timing measure addresses the number of ASC admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infection, who received the prophylactic antibiotic on time.


The antibiotic needs to be administered on time, which means antibiotic infusion is initiated within one hour prior to the time of the initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope, insertion of needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are administered.


Studies indicate that appropriate preoperative administration of antibiotics is effective in preventing infection. This performance measure is in accordance with current surgical infection prevention guidelines.


A reasonable goal for this measure is an on-time administration rate in the 98-100 percent range.


Q: Patient fall in the ASC?

DS: The patient fall in the ASC measure addresses ASC admissions experiencing a fall within the confines of the ASC. Due to the use of sedatives and anesthetic agents as adjuncts to procedures, patients undergoing outpatient surgery are at increased risk for falls.


A "fall" is defined by the National Center for Patient Safety as "a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions."


A reasonable goal for this measure is no patient falls within the confines of the ASC.


Of note, while you may be tracking all of your patient falls, this measure is only looking at falls within the ASC.


If your facility is experiencing falls, the Agency for Healthcare Research and Quality's Prevention of Falls in Acute Care guideline says patient falls may be reduced by following a four-step approach:

  1. evaluating and identifying risk factors for falls in the older patient;
  2. developing an appropriate plan of care for prevention;
  3. performing a comprehensive evaluation of falls that occur; and
  4. performing a post-fall revision of plan of care as appropriate.


Q: Wrong site, side, patient, procedure or implant?

DS: The wrong site, side, patient, procedure or implant measure addresses all ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or wrong implant. The Joint Commission's "Universal Protocol" is based on the consensus of experts from the relevant clinical specialties and professional disciplines and is endorsed by more than 40 professional medical associations and organizations.


In many instances of wrong site occurrences, Universal Protocol was not followed and either the site was not marked or the time out was not completed.


For ASCs performing blocks, centers should perform time-outs for them just like you would for an OR procedure.


A reasonable goal for this measure is no wrong site, wrong side, wrong patient, wrong procedure or wrong implant events.

Q: Hospital transfer/admission?

DS: The hospital transfer/admission measure address ASC admissions requiring a hospital transfer or hospital admission upon discharge from the ASC. The need for transfer/admission is an unanticipated outcome and could be the result of insufficient rigor in patient or procedure selection. Hospital transfers/admissions can result in unplanned cost and time burdens that must be borne by patients and payors.


This measure will allow ASCs to assess their guidelines for procedures performed in the facility and patient selection if transfers/admissions are determined to be at a level higher than expected. If commonalities are found in patients who are transferred or admitted, guidelines may require revision.


The goal for this measure is not precisely quantified at this time because an average transfer/admission rate for ASCs has not been established.


Q: Appropriate surgical site hair removal?

DS: The appropriate surgical site hair removal measure addresses ASC admissions with surgical site hair removal with clippers or depilatory cream. Razors can cause microscopic cuts and nicks to the skin, not visible to the eye. Use of razors prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use or no hair removal at all.


Removing body hair with electric clippers or hair removal cream immediately prior to surgery reduces the likelihood of a surgical wound infection.


A reasonable goal for this measure is to assure that patients requiring hair removal at the surgical site have hair removed with clippers or depilatory cream 98-100 percent of the time.

Q: What should ASCs do with the data they collect on these measures?


DS: Don't just collect the data but analyze it. The ASC Quality Collaboration posts a quarterly quality report at www.ascquality.org. You can take your data and compare it to the data on the website. By benchmarking your facility with others in the industry, you can tell how you are doing compared to others. Benchmarking identifies your opportunities for improvement by letting you know where you are and helps you establish realistic goals of where you want to be.


If your data compares poorly with the benchmarks, dig in and ask why did this happen? Develop an action plan based on results. Get everyone involved in quality assessment performance improvement. If your facility is having issues in a particular area, get those closest to the problem specifically involved. Involve those that will impact the improvement.


The CMS Conditions for Coverage states the "ASC must develop, implement and maintain an ongoing, data-driven quality assessment and performance improvement (QAPI) program" (416.43) ). CMS does not prescribe the particular program; the ASC has the flexibility to establish its own however it must contain the five standards:

  1. Program 'scope'
  2. Program 'data'
  3. Program 'activities'
  4. Performance improvement projects
  5. Governing body responsibilities


The program must "include, but not be limited to, an ongoing program that demonstrates measurable improvement in patient health outcomes, and improves patient safety by using quality indicators or performance measures associated with improved health outcomes." (Conditions for Coverage; 416.43)


Summarize your project and improvement in a report. Describe the issue, the team, your analysis, actions taken and follow-up. Clearly communicate your data, goals and expectations to your staff, medical executive committee and governing body. And as you get closer to your goals, celebrate the small advances even if you haven't met your final goal.


Learn more about the ASC Quality Collaboration.

Related Articles on ASC Quality:

30 Predictions on the Future of Ambulatory Surgery Centers

State of the ASC Industry and Ambulatory Surgery Center Association: Q&A with Bill Prentice of ASCA

New Surgery Center Benchmarking Data: ASC Quality Collaboration Publishes Quality Report for 1st Quarter of 2011

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