8 ways ASCs are non-compliant on quality matters

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Non-compliance in ambulatory surgery centers is one of the most challenging aspects of maintaining quality programs and can have a significant impact on an ASC.

"In the short term, ASC staff members may miss the problems occurring every single day and find out later when it's a big issue, in a survey or when investigating an occurrence," says Jovanna Grissom, RN, CIC, regional vice president of operations, Meridian Surgical Partners. "You want to be continually identifying issues and implementing corrective actions so you are not finding out in a survey or when an adverse event occurs. Certain issues could mean losing your accreditation or certification."

There are a number of surprising ways in which ASCs can be non-compliant. They are:

1. Performance improvement study format. We see a lot of confusion in centers around what is really a performance improvement study and what is benchmarking says Ms. Grissom. Many ASCs do not properly format their quality improvement studies, leading to issues during surveys.

2. Peer-review component. At times, ASCs may not correctly complete the peer-review element of quality management programs, notes Jean Day, director of education at Pinnacle III.

"A lot of ASCs are merely performing a chart audit which isn't the same as evaluation of the performance of a medical practitioner by their peer-group," she says.

It is important for leaders to address ongoing professional performance which goes beyond the scope of a chart audit. Evaluating physicians' clinical performance with regard to other clinicians in your ASC is an important element of maintaining and improving quality.

3. Uniformity of time-out in the OR. Another common non-compliance issue is lack of adherence to a uniform and consistent time-out in the operating room. Facilities may have varied time-out processes, which can get confusing and lead to mistakes, and sometimes, sentinel events, says Ms. Grissom.

"This happens a lot," says Ms. Grissom. "Facilities must develop and enforce a policy that works for them in the prevention of wrong patient, site and procedure events."

4. Policy and process implementation. Develop and establish quality improvement policies and processes. Ensure that staff are trained on these and reminded of them on a regular basis. Institute training on quality-related policies and risk assessment programs more than once a year, says Ms. Grissom.  

5. Ongoing monitoring. Training and education on quality improvement, along with monitoring, needs to be continuous, notes Ms. Grissom.  

"When we train staff members to do something we need to keep checking in on them," she says. "Monitoring has to be done to prevent falling back into old habits and reinforce what we are teaching."

ASCs are typically lean facilities where efficiency is of utmost importance. In an ideal world, surgery centers would have a staff member dedicated to quality improvement and compliance. However, this is not possible at every center so it’s important that the entire staff takes responsibility for it.  

6. Ongoing data collection. "A quality improvement program is aimed at identifying root causes of problems rather than just superficially addressing one issue at a time," says Sandy Berreth, director of operations at Pinnacle III.

The key is in the process. Writing up and justifying a one-time occurrence does not create the framework for a quality improvement program. Regular collection and analysis of quality data allows staff members to actively address considerations that could potentially result in non-compliance, she says.   

7. A model of change. Establish a model process for change. "If something needs to be changed, identify why [data collection], then identify what needs to be changed to improve the outcomes. Finally, identify how you can make the change [performance improvement]," says Ms. Berreth.  

Every time you change something, write it up and report it in your quality committee meetings to ensure you do not miss out on opportunities to improve the quality of your ASC's performance.

8. Using technology. When ASC personnel are hesitant to embrace new technology, efficiency is compromised, leading to possible quality issues. Many ASCs are still using paper-based tools and technology is underutilized, notes Ms. Day. A number of processes can be automated, which is especially useful in the surgery center's lean environment.

"Everything from hand-off communications to medication reconciliation can be monitored and quantified as a metric of performance then reported through automation of software as a solution," says Ms. Day.  "It astounds me how difficult quality management has become. It behooves ASCs to move forward with implementation of the technology that is available to streamline processes wherever possible."


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