On the lighter side..

Ortmann Healthcare Consultants Family Photo

You may have noticed a lapse in posting two weeks ago. Well, that was due to the marriage of a staff member- Congrats to the new Mr. and Mrs. Brian and Jessica Miller!

“Clinic Reports Lapses in Disinfection”

“Clinic reports lapses in disinfection” Las Vegas Sun 12/31/08 Not a headline I’d like to read in my hometown newspaper….or is it?

With over 16 years of endoscopy experience in the state of Florida this report struck a nerve, especially looking back at the last 3 years as director of an outpatient endoscopy center. One of the checks and balances that the state of Florida has in place in the outpatient setting is a licensed risk manager. Our risk manager was an active part of our Quality Assurance team, meeting quarterly with team members, providing mandatory annual risk management in-services to all staff, and being “on call” to review incident reports generated in the center. There were certain “incidents” that required the state to be notified within 24 hours such as wrong site surgery or death in the ASC. Other issues allowed more time for the risk manager to file a report to the state. One of the advantages of working with a qualified risk manager is experience in identifying any process that failed resulting in a poor outcome, implementing a change, and monitoring that change to document an improved level of patient care.

As I read the article in the Las Vegas Sun, my first reaction was “glad I don’t live in Las Vegas!” It was the staff at this facility, acting as members of the quality assurance team, who identified and reported a deviation in policy and manufacturers recommendation. The problem was identified and corrected but this facility did not stop there. This “incident” was reported to the state health division licensing the facility as well as the CDC. After speaking with the manufacturer of the scope washer and CDC, state health officials did not recommend that patients who have been treated at the facility get tested for hepatitis B, hepatitis C and HIV. The surgical center, however, is offering counseling and testing to any patients requesting this service.

As nurses and technicians we can all benefit from this reported “incident”. Currently any Ortmann Healthcare ambulatory surgery centers we develop have as part of their Policy and Procedure Manual, a checklist for Environment of Care; which identifies mechanical settings for different systems and equipment used in an ASC for patient care. By simply inserting our Endoscope Washer Checklist, the manufacturers settings for disinfection, anyone following a daily checklist can verify that the settings are correct. Are you currently using daily checklists to verify the correct manufacturers settings for each piece of equipment used in your ASC?

We can never be too diligent in identifying indicators that monitor our quality of patient care. Regardless of whether your state requires a licensed risk manager, or a staff nurse acts as the risk manager, we all have the same responsibility of improving patient care. Although no one wants to read about potential harm to a patient, as healthcare workers we must learn from any flawed process identified that will help make other outpatient surgery centers error free. I applaud Specialty Surgicare of Las Vegas for reporting the breach in infection control and taking ownership of the process to improve the future care of their patients.

Submitted by Nancy Nemeth, RN, Director Clinical Affairs

CON: The Big Debate

Certificate of Need, the remnants of Public Law 93-641, better known as the National Health Planning and Resources Development Act, that beast of burden for those in CON states! The intent of Certificate of Need regulations is to control health care costs through coordinated planning of new health services, but the regulation can also prevent the introduction of new services and health care delivery options. Recently the CON regulations of many states have come under scrutiny, which begs the question: If there were no Certificate of Need requirements, what changes would we see in our health care delivery systems?

This can be a very loaded question, and there are certainly two distinct patterns of thought. There are those that agree that the regulations are necessary to control cost and prevent duplication of services, and those that feel that a more competitive free market would lead to a decrease in cost and increase in quality. But there are many other factors to consider as well- physician shortages and economic conditions to name a few.

What do you think about Certificate of Need? Are you in a CON state and how has it affected your plans to introduce a new health service?

Florida ASC forced to close

Outpatient Surgery Magazine is reporting the closure of another ASC due to improper practices and lax managerial oversight. This time the facility is located in Florida. The full article from Outpatient Surgery Magazine can be found here.

Reading articles like these should serve as reminders of the importance of a sound Policy and Procedure manual, one that is not only properly written, but that the staff has been educated on and accepts as the rules and guidelines for operating in the facility. The state agency will almost always inspect a facility that they have received complaints about, but they also have the authority to inspect your facility at any given time, with or without notice. Having appropriate policies in place and assuring that these policies are followed is the best way to maintain your licensure. If you anticipate an inspection or just feel that is it time to review your manual, Ortmann Healthcare Consultants can help. Contact us today at 803-252-7979 for assistance in addressing your ASC clinical and regulatory needs.

Submitted by Jessica Miller, Director of Regulatory Affairs

Last Chance!

Just a reminder that the ACHE Webinar “Ambulatory Surgery Centers- The Basics and Beyond” presented by Fred Ortmann, president and CEO of Ortmann Healthcare Consultants is TOMORROW, Wednesday February 18th from 12:00 PM-1:30 PM EDT. For more information about participating in this webinar please visit the ACHE website.

Dear President Obama

Dear President Obama,

I understand that you are concerned about the cost of healthcare in the United States. I share your concern, and I know there is no easy answer to this problem. But, I would like to talk to you about something that I simply don’t understand—the behavior of managed care insurance companies in the United States when it comes to contracting with Ambulatory Surgery Centers.

When a patient has surgery in an ASC, the patient saves and the payor saves because it is simply less expensive to have a procedure performed in an ASC than in a hospital outpatient department (HOPD). Most insurance payment rates are based on a percentage of what Medicare pays for its procedures. CMS has studied surgeries done in both ASCs and HOPDs and has determined that ASCs should receive a lessor amount for the procedures it performs compared to HOPDs. While how much less in payments an ASC should receive is hotly debated (and a topic for another discussion), the fact remains that ASCs are paid less for the same procedure performed in an HOPD.

This generates savings for patients in co-insurance and deductibles. Right now the overall average ASC payment is 59% of what Medicare pays HOPDs, although the initial figure was supposed to be 65% (a discussion for another time). If a patient is paying 20% of the charge, it’s easy to determine which payment is less. And if the patient hasn’t met his deductible, then the patient could be paying for the entire procedure or most of it. Especially in this time of economic hardship for so many people, this difference could be the deciding factor in whether a person decides to have a surgery or puts that surgery off until later, sometimes a life-threatening decision.

And let’s get the safety and patient care issues out of the way. There are no studies that demonstrate it is less safe to have a procedure performed in an ASC than in a hospital. In fact, there are many who believe it is safer. The American Academy of Orthopaedic Surgeons’ website has a nice article on ASC safety, well documented by studies and journal articles. (http://www3.aaos.org/member/safety/ascreport.cfm) Regardless, overall having surgery done in an HOPD is safe; having surgery done in an ASC is safe. Both are highly regulated.

ASCs are strictly regulated by both Medicare and State Licensure requirements from both facility and clinical aspects. Most managed care companies require Accreditation by AAAHC, Joint Commission or AAAASF. Accreditation provides even stronger standards than Medicare certification or state licensure.

So, if it is less costly in an ASC for a managed care company to pay patient fees and less costly for the patient, the true customer of the managed care company, then you would think these companies would welcome an ASC into the market and quickly try to contract with it. President Obama, this is what makes sense to me—saving healthcare dollars by both the insurance companies and the patients in a safe environment.

But what makes sense to me apparently doesn’t make sense to some of the managed care companies, too many in my opinion. The first hurdle is to get the managed care company to even talk to the ASC. Phone messages are not returned, emails not answered. Sometimes it’s even difficult to find a contact person to work with. It takes great perseverance (stubbornness) to even get a person to send an application to the ASC. Even once the application is received it can takes days and weeks to get anyone to approve the paperwork or acknowledge that the paperwork is complete. During this time, the eligible ASC patients must be seen in the more expensive hospital setting. And so, President Obama, the insurance company and the patients pay higher rates. Below is actual verbiage from our correspondence to a managed care company after we reached a certain level of frustration:

“I am sure you are overwhelmed by the many responsibilities of your position, as we all are. Nevertheless, I called you almost three weeks ago and spoke with you about a contract for the XXXXX Surgery Center. You told me at the time that Dr. XXXXX was coming in town the following week, that you would see him on Wednesday, and have a response back to me by Friday. Friday came and went, and then on June 30th, 2008 you sent me an email and gave me the impression that you would get back to me shortly. I have called you several times this week, (two weeks later) and haven’t received a return call from you. Please understand that when you tell me something, I believe it, and I then give this information to our client, and when the client never hears from me, my credibility is questioned. We would very much like a contract with you as I mentioned and hope to hear from you very soon. In the interim, your company must pay hospital rates for endoscopy services, and your company is likely losing a substantial amount of money. I will be out of the office this week, but will answer my cell phone, the number is listed below, and I will be responding to my email. Your assistance in this matter will be most appreciated.”

The response received after this note was basically that multiple departments had to review the material and that can take a very long time.

After completing the reams of paperwork so that the managed care company will talk to the ASC, the next hurdle is to get decent contract pricing. In some geographic areas, it is not uncommon to be offered less than Medicare rates. While the healthcare system was designed for Medicare to set the lowest payment rates for our senior citizens, who for the most part are not working and paying a small Medicare insurance premium, while the private payors would pay a higher rate for those patients who are working and paying higher insurance premiums, ASCs are often offered rates below Medicare, at Medicare or barely above Medicare. Managed care companies in California, Florida and Ohio are particularly notorious for these contracts. Sometimes these offers are so low that ASCs must decline these sub-offers because it is impossible to cover expenses, which means the patients with these particular insurance plans are seen in the hospital. And so, President Obama, the insurance company and the patients pay higher rates.

The latest hurdle I’ve come across is in Florida where a particular managed care company refused to even offer a contract to an ASC. The company said that there were abundance of participating ASCs in Florida, and no network need for an additional ASC in Sarasota County. This particular doctor who opened the ASC could only get 3 hours a week in an ASC close to this practice. To find another available ASC that had time for him, his patients would have to drive 45 minutes to an hour. His patients don’t want to change physicians and don’t want to drive that far, so he takes them to a hospital for procedures. And so, President Obama, the insurance company and the patients pay higher rates.

Other managed care companies have given this ASC a contract. Why should another company refuse a contract because there are too many ASCs? Isn’t that our market place at work? If there are too many, one will go out of business, the one that doesn’t provide good service or care to its patients. And why should a managed care company be the one to decide which ASC should go out of business, if that is even a valid assumption. The one that goes out business should be the one that is managed poorly, does not provide excellent patient care, or does not have enough patients to stay in business, not the ASC that can’t receive a contract because some company bureaucrat decided he would refuse a contract to it. By the way, this ASC has not gone out of business, even without this contract, and I’m not aware of any other ASC deaths in that area, so I have to question the particular methodology that is being used to determine one ASC should not have a contract.

I just don’t understand President Obama. One study in 2003 showed that if all ASC eligible procedures were moved from the hospital to the ASC, over $1.5 Billion dollars could be saved. This study looked at only Medicare payments; the difference should be greater in a study of managed care rates. Why are these companies making it so difficult for ASCs to receive decent contracts or even to receive a contract? In the meantime, President Obama, the insurance company and the patients pay higher rates and healthcare costs continue to escalate. I just don’t understand. I hope you have some ideas.

Outpatient Surgery Magazine Sharps Article

It is amazing how many phones calls I receive from centers where a significant number of staff are being stuck with a sharp. An article today on the Outpatient Surgery Magazine website has simple reminders that I would encourage you to share with your centers! Look through your sharps policies and update them if needed.

1. Account for all pointed instruments. “Policies for passing, cleaning and disposing of sharps should apply to all potentially dangerous tools and instruments. Scalpels and needles cause the most sharps injuries, but orthopedic wires, drills and other pointed instruments can penetrate skin.
2. Enforce a no-touch sharps policy. “Staff should attach and remove blades to and from knife handles with a heavy clamp or safety device — never their bare hands. You might consider purchasing retractable, disposable blades or knives with safety handles as an added protection. Also use an instrument, not your fingers, to replace trocar shields used with drains.”
3. Keep fingers from needles. “To remove a needle from a syringe, use a hemostat or safety device. Needles should never be purposely bent, broken, removed from disposable syringes or otherwise manipulated by hand. Employ a one-handed technique or use a mechanical device to recap needles and blades. When repositioning a needle for a left-handed surgeon, AORN recommends the use of heavy forceps instead of fingers.”
4. Place instruments in a neutral zone. “Injuries can occur when passing needles or blades, mounting or repositioning needles, or when tying suture with the needle still attached. The best way to avoid sharps injuries when passing is to place the instrument — always one at a time — in a neutral zone, such as a tray, rather than passing it from hand to hand. The neutral zone approach is consistent with the goal of maintaining a no-touch policy when handling sharps. If you don’t use a neutral zone, staff must follow strict guidelines when passing or returning sharps:
   • The sender and recipient make eye contact and verbally confirm that the sharp is being passed.
   • The knife, syringe or other device is passed with the sharp end pointed down and protected by the sterile person’s hands.
   • Retractable blades should be closed and pointed down, with the tips in view.
   • Only one sharp is passed at a time.
5. Contain all sharps on the back table in the OR. “Remove sharps from the field as soon as possible to reduce the risk of injury. Place all used needles, scalpel blades and other sharps in a puncture-resistant needle counter box for disposal. Place reusable sharps in a puncture-resistant container for transport to the reprocessing area.”
6. When to replace sharps containers? “Replace them when they’re 75 percent full, as injuries can occur when sharps are placed in overfilled counter boxes. Keep your sharps containers in convenient locations so staff don’t have to walk long distances to dispose of items such as trocars, wires and pins. The back table is a good spot for the needle counter box, which should never be stored on the Mayo stand or surgical field. Remove all stray sutures from needles, and use an instrument when counting sharps placed in the counter box. The scrub person must verify the number of blades before closing the box. During transport, ensure that the needle counter box is closed and no sharps are sticking through it.”
7. Stick with it! “In addition to regular check-ups with staff, use the sharps safety checklist below to evaluate compliance in the OR. The best way to monitor adherence to your sharps safety policies is by examining the behaviors and attitudes of your staff in practice and using that data to identify opportunities for improvement.”

Source: http://www.outpatientsurgery.net/2009/01/back_to_basics.php. Must have subscription to see online article.

Submitted by Sarah McKeever, RN, VP Clinical Affairs

It’s not too late- Register Now

Just a reminder that it is not too late to register for the ACHE Webinar “Ambulatory Surgery Centers- The Basics and Beyond” presented by Fred Ortmann, president and CEO of Ortmann Healthcare Consultants. The ACHE sponsored Webinar is on Wednesday February 18, 2009, from 12:00-1:30 PM EDT. For more information about participating in this webinar please visit the ACHE website.