Question of the Day- Florida State Reporting

Does Florida require mandatory reporting for ambulatory surgery centers?

Facilities that meet the definition of an ambulatory center are required to report ambulatory patient data in accordance with Chapter 59B-9, Florida Administrative Code (F.A.C.). You can find information regarding state reporting at the Florida Center for Health Information and Policy Analysis website. This website can be used as a reference when submitting and making corrections to your patient data report. Once you have accessed the website you will need to review the following documents:

• Reporting Period Schedule – The patient discharge data reporting schedule (1 page)
• Ambulatory/ED Patient Data Contact Personnel Documentation Form (1 page)
• Facility User Account Agreement Form – Form granting access to secure data upload internet site (3 pages)
• XML Schema – File format for reporting ambulatory patient data (7 pages)
• Sample XML file – Sample file of how your final report should look upon submission (3 pages)
• Chapter 59B-9 F.A. C. – Administrative rule mandating reporting of patient data to AHCA (9 pages)
• Ambulatory Patient Data Elements – A breakdown of all data elements in the file and its description (5 pages)
• AS/ED Audit Dictionary – A spreadsheet of the all audits your data will be processed through and a detailed description of the audit error message. (9 pages)
• Physician License Number Format for state reporting – The DOH Florida Medical License Search website

The Ambulatory/ED Patient Data Contact Personnel Documentation Form and the Facility User Account Agreement Form can be found at the website with the Resources link.

If you are using any type of IT that assist in state reporting you will want to forward the link labeled Ambulatory/ED XML Schema to your vendor/programmer. This document is the file format for reporting. The Ambulatory/ED Sample XML File is how your data should look when it is received by the Agency. This should also be forwarded to your vendor/programmer.
Again, all of this information is available on the AHCA SCHS website.

Submitted by Jessica Miller, Director of Regulatory Affairs

Managing the Red Zone-Part III

Today’s post is the final in our series covering Management of the Red Zone in ambulatory surgery center development.

Planning in the Red Zone
If this were an ideal world and everything was perfect, we could generally rely on our time-line to help us complete the project in an orderly manner. The world, however, isn’t perfect, and rarely, if ever, is the best of time-lines. The successful coach learns quickly how to adjust his plays in the Red Zone when scouting reports prove unreliable during the game. When we are about to enter the “Red Zone”, it is time to stop and determine how well we have achieved our objectives and whether any adjustments must be made.

When entering the “Red Zone”, it is time for the principals on the development team to meet, assess their progress to date, and develop a detailed plan to finalize the project. At a minimum the meeting should include the developer, the architect, the general contractor, the equipment planner, the interior designer, and the Center Director.

The General Contractor is the key player in this meeting and should be asked when the Certificate of Occupancy will be received. The general contractor should be told that the ASC will be scheduling equipment deliveries, hiring staff, and purchasing services based on this date. The date must be accurate and we will expect him to jump tall mountains or hire added staff, if necessary, to meet the date he gives us. Some would say this date is a function of the dates stipulated in the construction contract; however, we don’t mention contract dates at this meeting, and prefer to ask the contractor to commit to an absolute date. We have generally found that a contractor will impose a more demanding date on himself than if we impose an artificial date on him.

In certain circumstances, it may be advisable to offer economic incentives if the contractor can accelerate the schedule. Once we have the absolute date for the C.O., we have our eye on the project goal, and we can identify all remaining key tasks and their required completion time, in order to successfully cross the “Red Zone”. A list of items to be checked is provided as Illustration 1. This meeting and our identification of all remaining tasks becomes our “Red Zone” plan, which should be typed and distributed to all participants.

Red Zone Management
Just as the head coach is in charge of his team, one person should be charged with maintaining the plan and communicating changes to all participants. Each participant must understand that any deviation from the plan must be immediately reported to the person charged with maintaining the plan. The person in charge likewise has to communicate all changes to all participants, and devise a means of overcoming any obstacles that may cause the plan to fail.

Once the plan is distributed to members of the team, weekly conference calls (or more frequently, if necessary) with all team members can reinforce the process, and keep the plan alive.

Our Experience
We have used the Red Zone management method for the past three years, and have finished ninety percent or more of our projects on time. We have learned:

1. Early focus on the completion of the project leads to consensus building and on-time job completion.
2. We are able to eliminate the development of most crises’ near the end of the project.
3. We have been able to achieve better planning among all members of the development team.
4. Working capital budgets are met and pro-formas are generally not exceeded.
5. Medical partners have a higher degree of satisfaction in the process.
6. General Contractors like the process and honor their commitments.
7. The ASC opens on time, sees patients rapidly after opening, and receives reimbursements from patient care early in the process of center opening.
8. We dramatically reduce the time needed to fully develop a center, and thereby, save substantial resources as a result.
9. We cross the “Red Line”.

And as today’s successful football team can only be successful by consistently scoring from the Red Zone, today’s successful ASC was likely coached during the development process by a team that understands the value of Red Zone Management, a team that knows how to cross the Red Line.

Submitted by Fred Ortmann, President, CEO

Managing the Red Zone-Part II

In this posting we will pick up where we left off last week discussing Red Zone Planning.

Mapping the Regulatory Process
For an ASC, proper execution in the Red Zone includes what you might call Mapping the Regulatory Process. Each state has a process whereby the state licenses and then, under federal contract, certifies the facility for Medicare participation. An uneducated prediction of the state licensure process is certain failure. Unfortunately, it’s rare for any two states to have the same process. It’s also rare to find a publication or guidance describing the various state processes, and rare that the same inspection agencies are used in any two states. Listed below are some of the state agencies this author has encountered in the various states:

• State Sanitarian
• State Fire Marshal
• State Department of Construction
• Board of Pharmacy
• Boiler Inspection Department
• Department of Radiation Protection
• Department of Hazardous Waste
• Department of Water Quality
• Department of Health- Licensure Division
• Department of Health- Medicare Division
• Department of Health- Medicaid Facilitation

There is always a pre-determined sequence that each agency follows to inspect an ASC, and scheduling the inspection at the various agencies according to their pre-determined sequence can take weeks. To avoid missing an agency inspection and delaying the project, it is a good idea to map the regulatory process in your state at the very beginning of the project. To properly map the regulatory process, you might want to visit your Department of Health (visit our Blog Post in the Regulatory category for a listing of state agencies) and ensure that you have identified all relevant inspection agencies and learn who schedules the inspections for each agency.

The Time-Line
The football coach has a playbook, and the ASC developer/owner should have a playbook, too. Time-Lines are management tools listing sequential step by step actions, matched with their respective start and end times, used by most project planning and management professionals. There should be a project time-line for each ASC to be developed. All project tasks, including those listed above dealing with regulatory aspects and inspection, should be integrated in the overall project time-line so that critical steps are not missed. Many computer software programs are available to help simplify this process for you.

Critical and Linked Tasks
There are some tasks that quite simply cannot be started and completed if the developer/consultant were to wait to begin the task’s implementation in the Red Zone, with only sixty days remaining on the project. There are also tasks dependent upon or linked to other tasks that must be done sequentially, which makes it almost impossible to start and complete such linked tasks in the “Red Zone” .
The critical tasks are primarily related to the acquisition of construction materials that require long lead times. Some of the products which require long lead times include:

• Heating, ventilation, and air-condition units
• Emergency generators and transfer switches
• Vacuum pumps
• Rated doors and door assemblies
• ADA compliant door hardware
• Concrete (very limited supply in some areas)

Other tasks are directly linked to another task which must be completed before the task can begin. Some of these tasks are:

• Completion of the CMS855-linked to Medicare Certification
• State Pharmacy License-linked to DEA License and necessary to purchase drugs and medical gases
• Acquisition of Center Insurance- linked to Managed Care Contracts

This is an extremly shortened list, as the number of tasks we have identified as necessary to complete the development of a surgery center number in the 700s!

Check back next week for our final posting in this series, covering Planning in the Red Zone.

Submitted by Fred Ortmann, President, CEO

Managing the Red Zone-Part I

In the next three weeks, Ortmann will be covering a topic relevant to a number of projects we are working- The Red Zone. The last 2-3 months when a project is nearing completion are the most crucial and good Red Zone planning will ensure your project is completed on time and on budget.

The Red Zone Defined for ASC’s
The development of an ambulatory surgery center can take between eight to twenty months to complete, depending on the availability of a pre-existing building. The “Red Zone” for the ambulatory surgery center is defined as the sixty (60) day period immediately preceding the date when the ASC is scheduled to receive its Certificate of Occupancy (C.O.) by the local building authority.

Why the ASC “Red Zone” is Important
The sixty days before an ASC gets its C.O. is a period of intense activity, a time when there is a virtual hemorrhage of capital and no transfusion of funds from patient care. During this time, final construction payments, the majority of equipment invoices, and many working capital bills will be presented for payment. The ASC center staff will be hired during this time, and many employees will be added to the payroll. If the individuals planning and developing the ASC prepared a realistic pro-forma before the development of the center began, which included not only financial data, but also accurate project development times, then there should be no problems. However, anything that delays the C.O. presents a significant obstacle to financial success as the entire project could be delayed by months.

There are many ways to fail in the “Red Zone”. If you fail to have the boilers on your sterilizers inspected, don’t timely apply for a pharmacy inspection, don’t timely complete and submit the CMS 855, or fail to properly implement any one of perhaps a hundred other tasks, you could potentially fail a state inspection. In most states, failure to pass an inspection means you go to the back of the line for re-inspection. This type of glitch could delay your project by one to two months. The additional time needed to open the center due to the glitches was probably not anticipated in the pro-forma, which means that you will likely need additional working capital from either the owner, or additional loans. Regardless of the source of the additional monies, the added debt will delay the time when the ASC becomes profitable.

The Crisis CAN BE AVOIDED
Many of the crises encountered near the end of a project can be avoided if the project is properly planned from the beginning: by mapping the state regulatory process, by developing an integrated time-line for all project tasks, and by identifying and completing critical tasks early in the development process. Please check back next week for the second posting in this series where we will cover Mapping the Regulatory Process and discuss Red Zone Management.

Submitted by Fred Ortmann, President, CEO

Patient Disclosure for Same Day Surgery

Medicare announced today that it would allow for an exception for same day surgery when it comes to meeting the new standard of the patient signing informed consent and financial disclosure the day before the surgery. The ASC Association announced this news through an email press release. Below is an excerpt of that email.

“It is not acceptable for the ASC to provide the required notice for the first time to a patient on the day that the surgical procedure is scheduled to occur, unless:

• the referral to the ASC for surgery is made on that same date; and
• the referring physician indicates, in writing, that it is medically necessary for the patient to have the surgery on the same day, and
• that surgery in an ASC setting is suitable for that patient.

In such situations the ASC must provide the required notice prior to obtaining the patient’s informed consent. Cases of surgery occurring on the same day it is scheduled are expected to be rare, since ASCs typically perform elective procedures. Frequent occurrence of such cases may represent noncompliance with the advance notice requirement.”

More information is available on the ASC Association Website.

Red Flag Alert Requirements Apply to ASCs

The Federal Trade Commission has issued “Red Flag” Requirements for Financial Institutions and Creditors in an attempt to fight identity theft. And while there was some question as to whether these requirements would apply to Ambulatory Surgery Centers, it has been determined that ASCs qualify as “Creditors,” and so the regulations are applicable to ASCs. This means that ASCs have until August 1, 2009, to comply with the FTC’s Red Flag Requirements (the more recent compliance date was in May).

Ambulatory Surgery Centers (as well as Physician Offices) are defined as creditors because each is considered to extend credit to patients on a regular basis, renew credit or to arrange credit for others. The definition includes all entities that defer payment for services. While many ASCs and Physician Offices may have policies of collecting payment before services, I believe most give at least some patients a grace period from time to time and so would meet the definition of creditor.

To comply with the Red Flag Rules, ASCs must develop a written program that identifies and detects the relevant warning signs – or “red flags” – of identity theft. According to the FTC, these may include:

• unusual account activity
• fraud alerts on a consumer report, or attempted use of suspicious account application documents
• suspicious documents

The program must also:

• describe appropriate responses that would prevent and mitigate the crime and detail a plan to update the program
• be managed by the Board of Directors or senior employees of the financial institution or creditor
• include appropriate staff training
• provide for oversight of any service providers

Wow! What does all of that mean for you? Well, primarily that you have to get a written program in place by August 1. One way to setup your program is to go to the FTC website where you can find a pdf document that will walk you through setting up a program.

Another idea is to go to the ASC Association’s web site, where they have a sample Red Flags Policy for your use. (While you’re on the ASC Association’s web site, you might consider joining as they have many helpful resources for ASCs.) If you have any other questions about the Red Flag Program and how to implement one in your surgery center, contact Ortmann Healthcare Consultants at 803-252-7979!

Submitted by Chris McMenemy, VP Administration

Benchmarking in your Surgery Center

Ortmann Healthcare Consultants is pleased to announce the initiation of their Benchmarking Program. We are currently looking for centers interested in benchmarking with other centers around the country. At this time, the program is only open to gastroentestianl endoscopy centers, as there is an immediate need for specific benchmarking data relevant to GI procedures.

If you are interested in participating, please contact Jessica Miller at 803-252-7979 to receive the survey form.

As a side note, OHC will be taking a short hiatus from posting for the rest of this week due to traveling. We will be back to posting on Monday! Have a great week!

Physician Credentialing

Physician and allied health professional credentialing is a topic that is often overlooked during the development of any ambulatory surgery center, even though proper employee and physician credentialing files are a federal, state, and accrediting agency requirement. Keeping organized and complete credentialing files makes it easier to assess new staff and can speed up the process of re-credentialing. Here is an overview of a few key elements of a physician credentialing file and how to make sure your records can stay organized and up to date.

Utilize a credentialing checklist:
Create a checklist of the items that are required in each credentialing file. Create a binder system that allows you to personalize a folder for each physician and store items behind appropriate tabs or markers to keep organized. Key items should include Medical License, DEA and any state issued certificates, medical malpractice insurance cover sheets, American Medical Association (AMA) and National Practitioner Data Bank (NPDB) query responses, Board Certificates, and Continuing Medical Education records.

Periodically Review Credentialing files:
Most physician credentials are reviewed for appointment and then often stored away until there is an incident or it is time for re-appointment. Since re-appointment sometimes does not occur for at least two years (depending on how credentialing and physician appointment is addressed in the Medical Staff Bylaws), many items in the file may become expired or obsolete. A physician may get any number of licenses or certifications renewed through the year, as well as changes in insurance and reports to the NPDB. You should be aware of any changes in medical or insurance information and collect any updated documents from the physician as soon as they are available.

Utilize your IT system:
Depending on which scheduling or ASC management software you have purchased, most have a tool included to store and track physician information. Through this tool you are able to set up alerts for physician information and can be notified when a license is about to expire. Some software programs will even suspend scheduling for that physician or bring up an alert until the document is reviewed and renewed. This is a great tool and can make periodically reviewing a physician credential file as easy as reviewing the information in their physician profile in your scheduling software.

Keeping good credentialing files is not only a must to meet federal, state, and accrediting requirements, but it makes good sense in protecting your patients!

Submitted by Jessica Miller, Director of Regulatory Affairs

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

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