Leapfrog's inaugural ASC survey 'disheartening,' has 'little value,' administrators say

With more than 60 percent of surgeries taking place in ASCs and outpatient units, The Leapfrog Group decided earlier this year to begin collecting quality and safety data on the increasingly popular facilities. Initially, the effort was met with enthusiasm.

Leapfrog received "endless phone calls" from ASCs wanting to participate in Leapfrog's voluntary survey, indicating they were "anxious to show their value in the open marketplace," Leapfrog President and CEO Leah Binder told Becker's ASC Review at the time. William Prentice, president and CEO of the Ambulatory Surgery Center Association, said the survey could be another opportunity to support price and quality transparency, although he had "some misgivings" about whether Leapfrog would render judgment without sufficient data.

Leapfrog launched the ASC survey April 1, along with a section for hospital outpatient departments on its hospital survey, which has been assessing inpatient care for nearly 20 years. By the Aug. 31 deadline, Leapfrog received submissions from 321 ASCs. In October, Leapfrog compiled the data and presented it alongside data from 1,141 HOPD respondents.

In an executive summary of the findings, Leapfrog highlighted what it called "gaps" in board certification among ASCs and HOPDs; low adoption of antimicrobial stewardship among ASCs; and low implementation of electronic hand monitoring in both settings.

These were just a few of the conclusions ASC administrators took issue with, despite earlier excitement about the survey. Those interviewed by Becker's ASC Review over several weeks expressed numerous concerns about the survey's methodology and value.

Setting standards

While Ms. Binder told Becker's ASC Review that Leapfrog was pleased with the number of ASC respondents — which exceeded the initial goal of 250 — Mr. Prentice noted that the data represents a small fraction of the 5,800-plus Medicare-certified ASCs in the U.S.

He and others also criticized the makeup of the panel of experts who helped develop the survey. Panelists included physicians and leaders from Pittsburgh-based UPMC, Baltimore-based Johns Hopkins and national nurse organizations, but none held ASC-specific titles.

According to Michael McClain, executive director of ASCs at Renton, Wash.-based Providence St. Joseph Health and former executive director at Seattle-based Proliance Orthopedic Associates, the panel's composition contributed to "incredibly acute care-centered" questions that relied on standards common in the hospital outpatient setting but not in an ASC.

"I don't think it necessarily reflected the differences in how we provide care, how patients are screened, the patient type or technology type, and staffing models that sit in the ASC," he said.

There were differences between the ASC and HOPD surveys, but for the most part, Leapfrog kept questions the same, according to Ms. Binder. As a standards-setting body, she said, Leapfrog included questions that went beyond minimum requirements to be accepted in the field.

"We tried to keep them as uniform as possible because we want consumers to be able to compare places where they might seek same-day surgery," Ms. Binder said. "So, whether it's an ASC or a hospital, they should, for example, expect to have someone with advanced life support on site."

Leapfrog also chose to highlight board certification across both settings, citing a correlation between board certification and infection control. However, Mr. Prentice questioned whether there's evidence that board certification and other measures Leapfrog highlighted actually translate to better outcomes.

"I'm sure there is a surgery center or a hospital out there that doesn't have board-certified surgeons providing care, and they've had excellent outcomes. And there's another where there are board-certified surgeons, and they have had bad outcomes," he said.

Patient safety indicators

Leapfrog's goal was to gather data useful to employers, as well as to patients shopping for care, according to Ms. Binder.

"We're asking about the factors that we consider critical to a high-quality surgical experience, whether you're at an ASC or a hospital," she said. "What Leapfrog is saying on behalf of employers is we'd like ASCs and hospitals to be putting all efforts [into what] we see as the gold standard."

Because of this approach, some questions dealt with rules and regulations that haven't been required in ASCs — or, in some cases, HOPDs. For instance, Leapfrog reported that adoption of safe practices endorsed by the National Quality Forum was higher among HOPDs, but that it's "likely because hospitals have been asked to comply with these practices for many years," the report states.

Compared to hospitals, ASCs also reported lower compliance with Leapfrog's nine-item Never Events Policy, which Leapfrog has been asking hospitals to adopt since 2007. Other survey questions related to patient safety revealed that only 18 percent of ASC respondents had an antimicrobial stewardship program in place, compared to 93 percent of hospitals.

It was "disheartening" to see these kinds of questions that catered more to resource-heavy hospital settings, said Suzi Walton, administrator of Columbus-based Ohio Surgery Center.

"Some things they were asking to be done were far past regulation, like antimicrobial program requirements," she said. "There's not a single evidence-based [antimicrobial] program needed in the ASC. It's left out of [The Joint Commission's] sentinel alert."

Ms. Walton was referring to The Joint Commission's antimicrobial stewardship requirements set to take effect in 2020; the accrediting body explicitly stated that the requirements are not applicable to ASCs.  

Information on antimicrobial stewardship wasn't available for HOPDs due to a lack of reporting tools, so ASCs were compared to hospitals. Ninety-three percent of hospitals, which use far more antibiotics than ASCs, had adopted a program to promote appropriate antimicrobial use.

Patient experience measures

ASCs were also compared to HOPDs on patient satisfaction, but Leapfrog's report focused on the questionnaire used rather than the actual scores. The group found that fewer ASCs than HOPDs reported administering The Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey to collect patient-reported data.

What Leapfrog didn't note, according to Mr. Prentice, is that the OAS CAHPS isn't required of surgery centers at the federal level — it was determined to be too burdensome, at 37 questions long and entirely manual.

"We thought there was a better way to do that and that there needed to be an electronic option. So we've been talking to CMS about trying to [develop one], and they're apparently pilot testing exactly that," Mr. Prentice said.

At ASCs that use the OAS CAHPS, patients do tend to report higher satisfaction than HOPD patients, Leapfrog found. But if they're not using the OAS CAHPS, almost every ASC still sends out a patient satisfaction survey after care is provided, Mr. Prentice said.

Regardless, Leapfrog holds OAS CAHPS as a standard of care, advising both ASCs and HOPDs to prioritize it.

A focus on processes

The focus on processes instead of outcomes frustrated Mr. Prentice.

"I believe the standard of care in the quality world is to focus more on outcomes rather than processes," he said. "So what we need through the CMS quality reporting program are more outcomes-based measures and measures that can be applied across settings."

The focus on process didn't necessarily put ASCs in a bad light; across the board, more ASCs than off-campus HOPDs had transfer agreements and policies for patients requiring a higher level of care. But it didn't showcase the data that ASC administrators consider to be most valuable.

"What I would find interesting, in terms of comparison, is use of the same-surgery checklist [and] measurements of perioperative time, OR time, hospital transfer, infection rates, falls, never events," said Mr. McClain of Providence. "I'd think we'd want to start by comparing things we're both held accountable to by regulatory and state organizations, then move to things that we can agree make sense to cover for both types of locations."

Outcomes are largely absent from the survey because there's a lack of vetted and tested measures, according to Ms. Binder. The group looks for measures endorsed by the National Quality Forum, used by The Joint Commission or otherwise verified and tested in the field.

"We are asking about things that are most important to safety and for which we can get good data. Unfortunately, we don't always have a good, fair measure. We can't ask about everything we want to ask about, infections being a very good example," Ms. Binder said. "Even though outcomes are a high priority, there are just not enough of those types of valid tested measures available for the survey yet."

In the future, Leapfrog does plan to report on outpatient infections, Ms. Binder said. To make that happen, the group is asking ASCs to join the CDC National Healthcare Safety Network's Outpatient Procedure Component module. Ms. Binder also encouraged ASCs to help develop the type of vetted, tested measures that Leapfrog wants to incorporate.

The next steps

Since publishing its initial report, Leapfrog has collected late submissions from 19 ASCs and shared proposed changes to the 2020 ASC Hospital Survey, which it's asking stakeholders to comment on by Dec. 20.

The proposed changes include new questions regarding participating in national clinical quality registries, new questions regarding safe opioid prescribing, and proposed scoring algorithms that will be used for public reporting on the individual facility level starting in July 2020.

"Results will be published in a way that allows consumers, purchasers and payers to compare ASC and HOPD performance side by side," the organization's website states.

With reservations about the survey's current value to patients and payers, Mr. Prentice said his organization will continue providing feedback.

"We were hopeful upon hearing about The Leapfrog Group entering into this space that if they did it judiciously that this is something that the ASC community might be able to embrace if it actually resulted in good data that would be valuable to patients and payers about where to seek care," he said. "My concern is this survey doesn't yet do that."

As is, the survey isn't necessarily damaging for ASCs, according to Mr. McClain. But if it remains an "apples-to-oranges" comparison, he said, "the survey has little value beyond outlining what we know is true: that hospital outpatient departments are different from ASCs."

In the meantime, Jeffrey Flynn, the administrator of Gramercy Surgery Center in New York City, said members of the New York State Association of Ambulatory Surgery Centers, where he serves as vice president, were encouraged to sit out the survey or proceed with caution. Ms. Walton, a member of the Ohio Association of Ambulatory Surgery Centers board of trustees, said centers should talk to their legal departments and boards about participation, while considering potential ramifications.

"As an ASC community, any time we do anything that represents the community as a whole, take a strong look at it to see if this is benefiting the community or detracting from the community," she said. "It's not that we have something to hide, but [that] lack of participation will motivate change."

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