CDC releases Ambulatory Surgery in the United States, 2006 Study

Yesterday, the CDC released it’s study entitled “Ambulatory Surgery in the United States, 2006″. A complete copy of the report is available for free here. This is an excellent resource for benchmarking and a great overview of where ambulatory surgery came from and the plans for the future.

Some interesting statistics to note: (copied from study)

• “Average times for surgical visits were higher for ambulatory surgery visits to hospital-based ambulatory surgery centers than for visits to freestanding ambulatory surgery centers for the amount of time spent in the operating room (61.7 minutes compared with 43.2 minutes), the amount of time spent in surgery (34.2 minutes compared with 25.1 minutes), the amount of time spent in the postoperative recovery room (79.0 minutes compared with 53.1 minutes), and overall time (146.6 minutes compared with 97.7 minutes).”
• “From 1996 to 2006, the change in the rate of visits to freestanding centers was larger than that for visits to hospital-based ambulatory surgery centers. The rate of visits to freestanding ambulatory surgery centers increased about 300 percent from 1996 to 2006, while the rate in hospital-based centers was flat.”

Submitted by Jessica Kopittke, Director of Regulatory Affairs

In Memory of Lynne

Our friend Lynne is gone today. She worked with Ortmann Healthcare Consultants on Wednesdays and Thursdays each week. She edited the policies and procedures our ASCs use as a starting point for their own policies, and she is gone because some horrible man shot her four times as she sat in her car at a drive-up ATM machine—a random act of violence that affected so many lives.

So, I guess I’m a little off subject this week, but it’s difficult to think of much else as I adjust to my Wednesday without Lynne. Lynne was in the position of having to re-enter the workplace after many years absent from it, and so to begin to build up a resume, she began working with us part-time. At first our plan was for her to serve as a receptionist, but we quickly moved her into the policies and procedures.

Policies and procedures make me want to scream and tear my hair out. I think I know a few other people who feel that way. There are so many; there is so much to read; there is so much to organize; and there are so many people working on them that it’s hard to keep it all consistent. But for Lynne it was a wonderful challenge. She didn’t have any clinical training, but she was smart and she could read material that sometimes made me just a little drowsy (or a lot drowsy). In some ways, too, having a non-medical person read words written by nurses has its advantages. For Lynne to understand what she was reading; the policies had to be clear; no step could be left out. If Lynne could mentally follow the procedure, then the document should be easy to understand and use by the clinical staff.

Despite my complaining, I do believe that these policies we use in our surgery centers are very important as a roadmap to how we do business. Having clear, well written documents is essential if the policies are to be followed and understood. We had the luxury of having Lynne to work on these documents while not all surgery centers are able to devote that time and energy. It is so important, though, to devote time to making sure your surgery center can be the best that it can be and good policies are a part of being the best.

Lynne was amazed as she began working for us of all the “stuff” that went into running a good surgery center or hospital—all the many, many details that had to be considered. She was so excited to talk to her brother, who is a cardio vascular surgeon, about her work. I guess it is fitting to know that as Lynne fought for her life, and knowing Lynne I am sure she was fighting, that those who were delivering her care were following their own policies and doing the best they could for her. When it is emergency time, it’s not possible to think “What should I do?” The staff has to have plans in place that have been validated and studied so that no time is lost in thinking about decisions.

Lynne didn’t quite finish her work, but I feel fortunate to have worked with her. It’s still impossible to believe that she’s gone. I thank the caring people at Palmetto Health Richland here in Columbia who did all they could for Lynne. Lynne, we miss your quiet presence here. And our policies and procedures will never be the same! I know God is with you and you are with Him.

Submitted by Chris McMenemy, VP Administration

Wrong Patient, Wrong Site, Wrong Surgery payment denial

Medicare recently announced that beginning on January 15, 2009 they would no longer reimburse ASCs, and other surgery providers, for surgery performed on the wrong patient, wrong site, or wrong surgery. The ASC Association has several links to information concerning the ruling from Medicare and the importance of eliminating these “never events”. According to the National Quality Forum (NQF), “never events” are “errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility”. “Never events” can reuslt in death or serious injury to the patient and increase the cost of providing healthcare because of the excess cost to remedy the event. The NQF has established 28 “never events”. A full listing of the events and other additional information is available at the NQF website.

One crucial step to achieve as a result of this announcement is for centers to prepare and implement a Wrong Patient, Wrong Site, Wrong Surgery Policy to ensure that these types of events are eliminated from occuring. We recently implemented a policy to cover wrong patient, wrong site, and wrong surgery events for use in our centers. If you need assistance in updating or writing your own Policy and Procedure manual, Ortmann Healthcare Consultants can help. Please contact us at 803-252-7979.

“Accreditation is a Key Differentiator in the Competitive Surgical Marketplace”

If you have been considering accreditation for your ambulatory surgery center or office based surgical practice then this article from SurgiStrategies is a must read. We have covered accreditation a few times on this blog and cannot stress the importance of obtaining accreditation for your surgery center. While it is not required, achieving accreditation is another way to show state authorities,the community, and most importantly your patients that you care about providing high quality health care.

Congratulations Parkridge Surgery Center!

Ortmann Healthcare Consultants is proud to congratulate Parkridge Surgery Center on being recognized in the Who’s Who in the Ambulatory Surgery Industry! Ortmann Healthcare Consultants served as the developer for this facility and wish to congratulate Parkridge and its staff on the recent recognition!

ASGE Endoscopy Unit Recognition Program

The American Society for Gastrointestinal Endoscopy (ASGE) has started a new program designed to promote quality in endoscopy. The ASGE Endoscopy Unit Recognition Program honors endoscopy units that follow the ASGE guidelines on privileging, quality assurance, endoscopy reprocessing and CDC infection control guidelines. You can read another article about the program here.

The ASGE recently recognized 56 endoscopy units for completing its requirements, the first units to achieve this recognition. Recipients are listed on the web site from above.

To receive this distinction, a center must currently be accredited by a recognized accrediting body, such as AAAHC, AAAASF, or the Joint Commission, adopt certain ASGE & CDC guidelines, and have a representative of the unit complete the ASGE course, “Improving Quality & Safety in your Endoscopy Unit.” The Certificate of Recognition award is granted for a three-year renewable period.

I just read about this program, and it seems like a relatively simple way for all the excellent endoscopy centers to receive recognition for their hard work and to assure their patients of their dedication to quality. There are so many centers that are following the practices encouraged by this program.

Endoscopy centers have had some bad press recently with a Hepatitis C outbreak in a Las Vegas endoscopy center that put thousands at risk. Then, recently, another Las Vegas center was cited for not disinfecting its endoscopes according to manufacturer’s guidelines for more than one year. This center probably wouldn’t have received as much attention if it hadn’t happened in Las Vegas and on the heels of the Hepatitis problem in the first Las Vegas clinic.

These types of stories worry the public, and rightly so. How can we be assured we are safe? Regardless of a center’s location, our patients deserve the best care we can give. Actively working to achieve a designation such as this is one way to keep quality at the forefront of all we do.

Submitted by Chris McMenemy, VP Administration

Patient Safety Resolutions for the New Year

A new year, a new beginning, but that doesn’t mean we should get rid of all the old habits! As you begin to look forward in the new year, take a step back for a moment to refocus on some important things to remember about patient safety.

To help, we recommend this list of 15 goals to check. This list came from a center we developed in the northeast, but these goals are applicable anywhere!

• Are you using two patient identifiers when administering drugs, i.e. in the PACU?
• Do you label containers for specimens in the presence of the patient?
• Are oral orders read back which is then confirmed by the individual who gave the oral order?
• Do you have the list of “do not use abbreviations” readily available and posted?
• Are these abbreviations(do not use abbreviations) not present in your orders, preprinted or manually entered?
• Have you identified the acceptable length of time for the reporting of tests, i.e. in endoscopy procedures?
• Do you have a “Look-Alike/Sound Alike” list from the formulary that is reviewed annually?
• Are all medications, on and off the sterile field, labeled with name and strength?
• Do you immediately discard any unlabeled medications?
• Are all original containers from medications available for validation until the end of the procedure?
• Have you implemented an anticoagulant policy? (Technically not an ambulatory standard but a very good idea)
• By January 1, 2010, are you prepared to show evidence that your facility has educated staff about health-care associated infections and the importance of prevention? Does this education occur upon hire and annually thereafter?
• Are you providing the patients on discharge with a “Reconciliation List”? Note: this is now a AAAHC expectation also.
• Focus on reducing the risk of surgical fires. Does your facility assess the risk of surgical fires based on equipment and procedures, used guidelines to minimize oxygen concentrations under drapes with appropriate staff training, and organize in-service on actions to take in the event of a surgical fire?
• Is the facility thoroughly familiar with the elements of performance to adhere to the “Universal Protocol” in conducting a preprocedure verification process?

These are just a few of the things you can do to monitor patient safety in the New Year. What else is your center doing to focus on quality in 2009?

Submitted by Sarah McKeever, RN, VP Clinical Affairs

Becoming Medicare Certified- Part III

CMS has issued a Tier 4 priority level for new ambulatory surgery center Medicare surveys, which means that many ASCs are seeking their Medicare Certification through an accrediting agency. This would be the third component of becoming Medicare certified. The first step is selecting an accrediting agency and completing the application paperwork. Make sure you select that you will be seeking Deemed status Medicare certification along with your accreditation survey. You should also alert the Medicare Carrier and state of your intent to seek certification in this manner.

After successful completion of your survey, the accrediting body will send you the notification and certificate. This usually leaves you with 3 loose ends to tie. CMS will notify you of their approval of your 855B enrollment application, which will need to be sent with your Medicare certification inspection from the accrediting body to the state authority. The state will in turn notify Medicare of your enrollment in the program. After all this, you will finally be issued a billing number and can begin billing!

Now of course, there are many exceptions to the process I have described in these three posts, and certainly each ASC has its own priorities in terms of Medicare certification, accreditation, and State licensure. If you are interested in more information or need assistance in certifying your facility, please contact Ortmann Healthcare Consultants at 803-252-7979.

Submitted by Jessica Kopittke, Director of Regulatory Affairs

Electronic Medical Records

One of my roles with Ortmann Healthcare Consultants is to help the ASCs we develop decide on information technology needs. I find most of our physicians want electronic medical records and do not want to build out the space in which to store patient records in their new ASCs. That is, until they discover what all goes into putting together a truly “electronic” record. (Unfortunately, discovering what goes into being paperless isn’t truly realized until the decision has been made to cut the medical records room in the ASC design.)

What I’ve found since I started working in this industry over the past five years is that it’s really easy to say “electronic record,” but more difficult to make it happen. I could probably write several times on this subject, but for today my focus will not be on any particular information technology system, but rather on the true difficulties of “paperless,” especially with new changes to CMS’s requirements for ASCs.

Other than putting together the actual software system, one of the most difficult things about going paperless is the amount of paperwork that a patient must sign (informed consent, HIPAA notification, financial disclosures, discharge instructions, to name a few) along with paperwork that may come from a referring physician. We get around this problem by scanning these items into the electronic medical record software that is used, so we can in the end become “paperless,” but printing out all of this paper sort of defeats the purpose of trying to be “paperless.”

It’s amazing how many pieces of paper must be generated for the typical electronic medical record. Part of the savings associated with these systems is not having to buy the folder for the chart contents, not having to buy paper to print out patient forms, and not having to spend as much time assembling the paper chart and paying the salaries of those who do the assembling. Now, please don’t get me wrong. We are saving money, even though we still need to do these things. We don’t need to print out as many pieces of paper, we don’t need to pay for dictation, we don’t need to spend as much time assembling the chart, but if we could be more paperless, we would save even more.

So as part of my job is to deal with the best way for our centers to handle all of this, you may imagine how pleased I was to find that Provation Medical, a company that I particularly like to use in the centers I work with, had released Provation EHR. One part of this software system is the ability for patients to sign paperwork electronically, much as you electronically sign for credit card purchases. Wow, I thought, this will eliminate so much paper! The patient will be able to read the document and sign—no paper and no scanning (saving even more time and salaries for that time). This could save 10 or more sheets of paper per patient.

Unfortunately, part of my “Wow,” though, was dashed all too soon. By whom? CMS, in its final rule for ASCs 2009. Typically most paperwork is signed in the ASC (and in hospital outpatient departments, too) on the day of the procedure. So, with this electronic signature available, patients could sign all of the required paperwork the day they arrive for their procedures, electronically, saving paper, time and a few trees. But CMS is changing all of this on May 18, 2009, with the implementation of new Conditions of Coverage. You can find more information about all of the changes on the ASC Association webpage.

Now several items have to be provided in advance of the date of the procedure: forms on patient rights, disclosure of physician financial interests in the ASC, information on the ASCs policies on advanced directives. And to prove that these items have been provided, the patient needs to sign each in advance of the date of the procedure (at least that’s my current understanding). So, unless the patient comes into the ASC before the date of the procedure to sign these items electronically, these items will have to be scanned into the chart.

So, this great new feature, will have limited usage in the ASC, unless CMS changes its mind next year about this new condition for ASCs.

This is another example of the ASC being held to a different standard than hospital outpatient departments. A hospital outpatient department does not have these “advance of the date” requirements. If a patient is seen by a physician one morning and there is an opening in the ASC or hospital for a procedure to be completed that afternoon, currently there’s no problem. But, on May 18, 2009, this will be a problem for an ASC as explained above. Not for a patient who has a procedure done in a hospital outpatient department, though. That patient can still be treated in the HOPD the same day. (Are HOPD patients more capable of digesting important paperwork while ASC patients must be given 24 hours or more to understand the same information?)

Obama has made it clear that he wants American’s healthcare system to move into using electronic medical records. I hope he can convince CMS to structure current policies so that ASCs can follow his lead.

Submitted by Chris McMenemy, VP Administration

Becoming Medicare Certified-Part II

After submitting your enrollment application to the Medicare carrier, you will need to contact the office in your state’s department of health, or similar agency, that oversees Medicare certification. This is an important step because even though Medicare is a federally funded program, it is administered individually within each state. It is important to notify the state, regardless of licensure requirements, of your intent to be Medicare certified. If you are in a state that requires licensure this process can be done simultaneously with your licensure request.

Before the changes to Medicare, the state would be responsible for inspecting your facility. Some states will still perform a Life Safety Code Survey, but the wait times for a certification survery have become extensive and in most states, they are no longer being performed by the state at all. However, you are still required to notify the state, as they perform the final steps for certifying your facility. Mainly this includes executing your “contract” with Medicare through the forms CMS 370 and CMS 377.

Your best option these days is to seek Deedmed Status through an accrediting organization. I covered two such organizations in an earlier post, and the third part of this post will have more detail on how this last important step will get your facility Medicare Certified.