Federal Funds Released to 12 States to Survey Ambulatory Surgery Centers

American Recovery and Reinvestment Act of 2009 (Recovery Act) Ambulatory Surgical Center Healthcare-Associated Infection (ASC-HAI) Prevention Initiative

Federal funds have recently become available for 12 states to survey ambulatory surgery centers. Kathleen Sebelius, Secretary for HHS, announced on July 31st that funding would be available for 12 states to survey more than 125 ambulatory surgery centers. The funding comes from the American Recovery and Reinvestment Act of 2009 (ARRA) and will be administered by CMS in the amount of $9.95 million.

The first 12 states to volunteer, and the amounts they were awarded are listed below:

• Arkansas- $14,000
• Florida- $16,250
• Indiana- $62,500
• Kansas- $53,500
• Maine- $13,500
• Maryland- $73,000
• Michigan- $53,000
• New Jersey- $125,000
• North Carolina- $34,000
• Oregon- $53,500
• Utah- $62,500
• Wyoming- $11,500
• Total for States & DC- $572,250

CMS believes the additional funding will assist in reducing the number of health care associated infections (HAI). The surveys will also ensure that facilities are following Medicare’s guidelines for infection control. The initiative includes the use of a new survey process and tool developed with the CDC. The tool is the infection control survey that is available at the end of the new Interpretive Guidelines issued by CMS.

The surveys should be completed by September 30, 2009. An additional $9 million in funding will be available in October for the remaining states to survey their ambulatory surgery centers. The CDC has also promised to make available an additional $40 million for states to create or expand their HAI prevention and surveillance efforts.
Additional information can be found at the following links:
Medicare Press Release
HHS’ 2009 Action Plan to Prevent Health care-Associated Infections

If you operate an ambulatory surgery center in one of the first 12 volunteer states and want to make sure your facility is prepared for a survey, contact Ortmann Healthcare Consultants at (803) 252-7979. We have the tools to help you prepare and a record of “No Deficiencies” for every licensure, accreditation, and certification survey we have participated in.

Preparing for Medicare’s changes to the Conditions for Coverage

Are you working in an ambulatory surgery center? Does the date May 18 mean anything to you? It should! That’s the date you are expected to comply with CMS’s new Conditions for Coverage for ASCs. The ASC Association has helpful information on this topic and Scott Becker’s ASC Review has a nice, easy-to-read document that shows the changes in the law.

It’s important that those in charge of ASCs read this information and make plans now to be in compliance by May 18. We are waiting for the Interpretive Guidelines to Surveyors to be published and will share that information as soon as we have it. These new Conditions for Coverage apply to all patients seen in the ASC, not just Medicare patients. This is somewhat of a departure from recent years.

In the next two blog postings, we will be talking about what you should be doing now to prepare for May 18. The first topic is Patient Rights and Reponsibilities.

Patient Rights and Responsibilities

A document outlining patient rights must be provided to the patient both in written format and verbally, in advance of the date of the procedure. The ASC Association is interpreting this rule to mean that you must have this document signed prior to the date of the procedure. If the document is not signed before the surgery, you are to turn the patient away.

How can you prepare for this? For many surgeries, the easiest thing to do will be to get this paperwork signed when the patient comes in for his or her initial appointment before the surgery. Don’t let that patient leave without signing the appropriate paperwork or without verbally explaining the paperwork contents. If you have a problem with a language barrier, consider contracting with a service such as Language Line, so that you have a way of calling someone to translate for you if necessary. Be prepared for this need now!

What about patients who will not be seen in the ASC prior to their procedure? You will need to have a workflow plan. You may want to have this document placed on your web site, so that your patient may download, print and sign the paperwork before coming into the ASC. And/or you may want to mail this information to your patients for signature prior to the procedure. In both of these cases, the ASC will need to call the patients to give the verbal notice to the patients. Document this call! Describe how important it is that the patient brings this signed paperwork into the office the day of the surgery.

Whether the patient is expected to sign in the office, sign via documents downloaded from the internet, or sign via documents that have been mailed, in all cases the ASC must verify that this has not “slipped through the cracks.” When compiling the chart for the surgery, make sure that the documents signed in the office are in the patient’s folder, so that you can know before it’s too late that the documentation has actually been signed. Don’t assume that the Office staff took care of this! You do not want to be in the position of turning a patient away at 7 am the day of the surgery. For those patients who are not signing in the office, make sure that one of your pre-procedure call questions has to do with patient rights. “Have your read and signed your Patient Rights document?” “Were these rights explained to you verbally?” Document the answers to these questions. If the answer is no, you are going to have to fax the written information to the patient or reschedule the surgery. Make sure your patients understand the consequences of not bringing this documentation with them to the ASC.

Do I like these new requirements? Absolutely not and I have written in a previous blog about this. (See the archives of the General category) But, it is a requirement of the ASC to participate in the Medicare program, and you must follow these requirements or risk losing certification.

In addition to the signed paperwork on Patient Rights, you must also post written notice of the patient’s rights in a location within the ASC likely to be noticed by patients waiting for treatment. The Waiting Room itself is likely the best location. The ASC’s notice of rights must include the name, address, and telephone number of a representative in the State agency to whom patients can report complaints, as well as the web site for the Office of the Medicare Beneficiary Ombudsman. (Click here for sample copy of Patient Rights Posting, this document can also be a template for the signed Patient Rights document)

The ASC must also disclose, if applicable, physician financial interests or ownership in the ASC facility. This disclosure must also be in writing and given to the patient prior to the date of the procedure. So, either combine this document with the Patients Rights document or create a separate document, and follow the procedures noted above. (Click here for a sample copy of a financial disclosure form)

Check back next week for the post covering Advanced Directives

Submitted by Chris McMenemy, VP Administration

Infection Control Surveys

The ASC Association released some information in an email update published yesterday regarding the Department of Health and Human Services intention to develop a new infection control survey tool for ambulatory surgery centers. If you do not currently receive ASC Association email updates you can sign up on their website. Copied below are the comments from the News Flash released by the ASC Association.

“Testifying before Congress today about preventing infections acquired in health care settings, an official from the US Department of Health and Human Services (HHS) announced plans to launch a new survey tool for ASCs. The ASC Association will provide more information on this new HHS initiative as it becomes available. A copy of the HHS official’s remarks directed specifically at ASCs follows.”

“To help prevent serious infections resulting from services performed in Ambulatory Surgical Centers, CMS will use the funds provided in the ARRA [American Recovery and Reinvestment Act of 2009] to implement the nationwide application of a new infection control survey tool developed in consultation with CDC [Centers for Disease Control and Prevention] and a case tracer methodology that tracks a patient’s care from admission to discharge. In addition, CMS will use the ARRA funds to survey Ambulatory Surgical Centers using this survey application at the rate of approximately once every three years during this national pilot.”

“A CMS[Centers for Medicare and Medicaid Services]/CDC pilot program tested the enhanced survey process in Maryland, Oklahoma, and North Carolina in 2008 and demonstrated superior results in the ability to detect deficient infection control practices. The particular focus on Ambulatory Surgical Centers for this funding was chosen because the available infection control tool was developed for Ambulatory Surgical Centers and because of the likely continuing infection control deficiencies in this setting.”

“The primary use of these dollars will be to pay for the expansion of Ambulatory Surgical Center surveys (both in quality, time, and number) using the new infection control tool and case tracer methodology. The funds will allow states to hire additional surveyors (one to four per state dependent upon Ambulatory Surgical Center growth), which will increase a state’s capacity to maintain expected levels of Ambulatory Surgical Center inspections while building greater capacity to use the improved survey tool nationwide. In recent years, funding for survey and certification activities supported recertification of Ambulatory Surgical Centers once every ten to fourteen years; this new funding will enable CMS to perform targeted survey and certification activities much more frequently.”

Reference: ASC Association News Flash Email update, published April 1, 2009.

“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

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

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

Infection Control in the Surgery Center

As a part of the aftermath of the highly publicized Hepatitis C outbreak in a Las Vegas endoscopy center this year, the Government Accountability Office (GAO) will sponsor a national study aimed at measuring the link between outpatient facility care and healthcare-acquired infections, according to Outpatient Surgery E-Weekly.The GAO notes the outpatient surgery industry lacks data on the frequency and characteristics of healthcare-acquired infections occurring in surgery centers.

My personal feeling is that ASCs will fare well in this study. The ASCs we work with are diligent in their infection control protocols, following well thought out policies and procedures. I believe the Las Vegas case is an aberration, not the norm. However, we can never be too careful and perhaps this study will encourage our industry to remain conscientious when it comes to the prevention of all types of infections.

This is a subject dear to my heart from personal experience. My Medicare-age mother (I don’t know if she wants to divulge her age!) had an infection problem last year after having toe surgery on both feet, which was performed in a hospital. After being home a week, she went back to her physician who , when taking off the bandages, immediately noticed that there was a big problem with one of the toes. He immediately placed her in the hospital for a week with an IV drip of antibiotics to try to stop what was obviously an infection in her foot. She was released after a week, but on her next check-up it was determined that she still had a problem.

So began an almost five-month ordeal to try to get rid of this infection and to save her foot or possibly her leg as she had had a joint replacement several years earlier. She was required to go to her local hospital daily for an infusion of drugs to fight this infection—every day of the week. As it was December and January in Missouri, (and I’m in South Carolina and not able to help that much) we were concerned about her having to get outside and drive to the hospital in all types of winter weather. (My dad has cancer, and although in remission, he receives chemo weekly and it is difficult for him to drive.)

While everyone had high hopes that this drug therapy would work, it was decided in January that she was not progressing. Next came more surgery and more everyday drug therapy. Only now she had to stay off the foot and couldn’t drive at all. And, while Medicare would happily pay for her stay at a long-term care center—where not only would the drug infusion be covered, but also the room, meals, nursing care, etc.—Medicare would not pay for a home health care aide to come to the home to give her the infusion daily—not the aide, not the drugs, nothing. Now, which do you think would cost the government more money?? But rules are not made to be broken when it comes to our government, no matter what makes sense, and my mother had to go to the hospital daily for the infusion or go live at the long-term care center for several weeks. Since she did not want to leave my dad, the hospital it was!

Fortunately, we were able to work out a plan for the hospital van to pick her up, and my sister, who lives nearby, was able to help on days she wasn’t working, and Mom was able to make it to the hospital. The combination of the second surgery and the drug infusion worked, and our story ended well. But this isn’t the case for so many people.

In an article in SURGistrategies, Infection in the ASC: Proper Protocol Supports Infection Prevention in ASCs, Debra Saxton Stinchcomb, RN, BSN, CASC, of Progressive Surgical Solutions, gives some good advice on how to avoid infections in your ASC. Some causes of infection include:

• Ineffective cleaning, decontamination, and sterilization of instruments and equipment
• Inadequate monitoring of cleaning and sterilization processes
• Inappropriate use of prophylactic antibiotics
• Shoddy hand washing and/or scrubbing of peri-operative surgical staff
• Improper skin preparation of the patient’s surgical site
• Break in aseptic and/or sterile technique during the surgical procedure
• Lack of environmental controls (pertaining to room cleaning, temperature/humidity, etc.)

Debra and others quoted in the article have additional advice, but stress the importance of an active surveillance program.

• Gather and track infection data
• Encourage surgeons to culture postoperative infections to assist the ASC staff in identifying the source of the infection
• Adhere to infection control procedures that are set in place

Never discount the importance of good educational programs, either. The average ASC employee knows that overall infection control and preoperative skin antisepsis is vital, but the extent of adherence varies, according to Ginny Lipke, RN, BS, ACRN, CIC, of St. Luke Hospital in Fr. Thomas, KY.

“It depends on the level of understanding that the employee has, and that’s where education comes in,” Lipke says. “It is also helpful to have managers and coordinators that embody the quest to implement best practices daily. Staffs model their behavior from what they observe around them, especially their leaders.”

The article has lots of good ideas and advice and I recommend it to you. I do believe that overall ASCs are doing a great job with infection control, but we can never be too vigilant when it comes to infection prevention.

Submitted by Chris McMenemy, VP Administration