Dawn Q. McLane, RN, MSA, CASC, CNOR, regional vice president of operations for Health Inventures, makes 10 points on complying with the new rule in the Medicare Conditions for Coverage, requiring ambulatory surgery centers to provide patients with certain written material before the date of surgery.
1. Day-before rule. The ASC must provide patients with specific information prior to the day of surgery. ASCs have been challenged by this requirement ever since it became part of the Conditions for Coverage on May 9, 2009. Since they do not usually see the patient before surgery, they had to develop ways to make sure the patient receives the required information. Ms. McLane advises that the best way to achieve compliance is to incorporate these requirements into what the ASC already does, such as distributing brochures to patients from the physician's office. "The success of the new processes can be tracked as part of the quality program and variances documented, trends monitored and actions taken to improve the process," she says.
2. What material must be provided. The required material includes a copy of the ASC's patients rights and responsibilities, disclosure of a physician's ownership in the ASC and information about the center's policies on advance directives, including providing the approved advanced directive form to the patient upon request. The center must document in the current medical record if the patient has an advanced directive and will usually request a copy of the document for the inclusion in the patient's medical record file. If the patient is transferred, a copy of the advanced directive should be included in the transfer chart.
3. Communication of the center's grievance policy. The ASC must also provide patients with information about the center's grievance process, which does not need to be done before the day of surgery, but it is usually included with the other material.
4. Waiver for urgent or emergent care. When the case involves a same day add-on urgent or emergent procedure, the material does not need to be provided to the patient a day in advance. However, the surgeon must document pre-operatively required elements on the appropriateness of performing the procedure in the ASC and verify that the procedure requires urgent care. Also, patient rights notification material must be provided prior to obtaining the patient's informed consent.
5. Mailing or e-mailing the material. Since the patient does not usually enter the ASC before the day of surgery, the ASC may choose to mail or e-mail the information. The required elements would have to be sent or attached in an e-mail, or the patient could choose to be directed to a page on the center's website. However, simply placing the material on the website is not sufficient. The patient needs to know it is there and to the center would need to verify that the patient has received it.
6. Make a follow-up call. In many cases, ASC staff members are already performing pre-op phone calls to patients to discuss their medical history and discuss information the patient needs to know about prior to their surgery. "This is also an opportunity to make sure they received the patient rights notifications," Ms. McLane says. Staff may verify with patients that they have received the patient rights notification documents from the physician's office or through other means. "It is only required that the patient rights notification has been provided to the patient, verbally and in writing, prior to the date of the procedure, in a language and manner the patient understands," she says. "It is not required that the patient verbalizes understanding."
7. Translate the material. Arrange to have the material translated into frequently used languages in your area, such as Spanish or Vietnamese. When patients speak an unusual language, you can use translation services on the Web. If you do not have staff fluent in the language of the patient, you may need an interpreter for the follow-up call to verify that patients have received the material. You can use telephone-based interpretation services for these calls.
8. Hand out brochures at the surgeon's office. Rather than rely on mail or e-mail, many centers have worked with their surgeon's office to distribute the patient rights notification brochures when patients come in for their pre-op appointment with the surgeon. It can be useful to design a form with all the required elements as a handout or a brochure, providing them to the physicians' office staff along with education about what and why this is required. "You may still want to make a follow-up call to make sure the patient has received the information," Ms. McLane says. Centers that receive urgent cases from the ED may work with the ED director to maintain a file of brochures in the ED so that they can be handed out to patients scheduled for the ASC either the same day or the evening prior to surgery.
9. Make sure staff are complying. Make sure staff members at the surgery center, surgeon's office and other sites understand the requirements and that surgeons are documenting emergent and urgent cases. As an AAAHC surveyor, Ms. McLane asks staff at the registration desk to explain how they meet the requirements for patient rights notification. In some cases, she finds that staff members are still confused or unclear about what is required. For example, staff may assume they can provide patient rights notification on the day of surgery.
10. Document variances. One way to assure compliance with the requirements is to treat the process as a quality assurance study to determine when you have variances and what contributed to the variance. Record all instances when the materials were not properly handed out and make a variance report, as you would do for other adverse events. As in all variance reports, explain the oversight, what caused the variance and what can be done to improve the process. Accreditation and Medicare surveyors would like to see evidence of compliance with these requirements.
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