5 Great Studies to Perform in an Ambulatory Surgery Center

The following article is written by Regina Robinson, RN, MBA, CMPE, CASC, director of Peninsula Surgery Center in Newport News, Va.

Part of every great organization's operation is a process to continuously look at opportunities to make improvements. While there may be many ways to do this, one method is to conduct a study. A study will allow an ambulatory surgery center to determine if there is a problem and if closer watching is warranted. The topics that can be chosen are vast and require personalization to each facility to determine what areas are the most troublesome and high risk.

Studies are usually conducted because of an accreditation requirement, but a study can also be done to have written documentation of a resolution to a recognized problem. This will allow a facility an opportunity to make improvements and monitor progress to a better outcome. The studies can be very complex or they can be simple; however, the studies should always be done for the same reason — to make improvements.

The idea of a study can come from current data collection trends, evaluation of a new piece of equipment, evaluation of the skills of the coder or charge entry clerk, or evaluation of the skills of the physicians.

The structure of a study should be the same and only the topic should change. Each study should determine what areas are affected by a recognized problem. This can be listed at the top so more than one can be selected. These could be clinical, administrative, cost of care or patient outcomes. The contents of the study are then broken down into the following seven different question components:

1. Problem identified: What is the suspected problem/concern?
2. Identification of performance measures/goals/objectives: What needs to be done to correct the problem/concerns? What is the goal to accomplish?
3. Research/gather data: What is the frequency, severity and source of the suspected problem/concerns?
4. Implementation of corrective action: What was done?
5. Re-measurements/re-evaluation: Was the desired goal achieved or should alternatives be considered?
6. Identification, analysis and implementation of any additional corrective actions: If the original corrective action did not resolve the problem, what is the next step?
7. Conclusion: The results of the study are evaluated and a conclusion is reached. Results are reported as appropriate.

This format gives a good framework for every study that is conducted and allows for personalization while showing substance. In the following sections are a few examples of actual studies that can be used or altered to meet the personalized needs of the ASC.

Denial rate

The purpose of this study is to determine the percentage or number of submitted claims that result in a denial. This should be determined because the accounts receivable (A/R) days are growing with the denials and this directly affects the business office and the financials. A quick investigation is warranted. A study should be developed to look at the current process and see if the problem can be located. Begin by collecting the accounts that have been denied.

Once the specific denied accounts have been identified, then a reason for the denial can be determined. Some common reasons are manual input error, insurance verification error, insurance company error or incorrect coding. While this is a short list of potential problems, it could affect many claims that could lead to a larger problem and a delay in reimbursements. One technique is to take a period of time such as two months and keep track of all the accounts that are denied. This study can be conducted on current daily time frame or it can be extracted from historical data. One important note to remember is if done on current data, the reasons for the denial should not be researched since this could flaw the study and this may delay actual reimbursement. Therefore, consideration should be made to determine if historical data would be the best method. Once the reasons are determined then a targeted solution can be done.

When the denied account information has been collected, it is time to determine the reasons for the denials. Is there a trend to a particular task or employee? Some common reasons are incorrect manual input of the account number or no confirmation of insurance verification. Break down the accounts to determine the exact reason for the error and when or how the problem developed and how to make corrections. Once the details have been gathered and the analysis completed, it is time to set up an action plan to make corrections. This should be specific to prevent this same problem from occurring in the future. Upon completion it is good to decide if this study needs to be re-evaluated in 6-12 months.

While guidelines are listed, it is permissible to alter the questions to meet the study requirements, but the base of the questions should remain the same. Here is a fictional sample of what can be written to complete this study based upon the above questions:

1. Problem identified: What is the suspected problem/concern? The A/R days are too many and more denial letters have been received.
2. Identification of performance measures/goals/objectives: What needs to be done to correct the problem/concerns? What is the goal to accomplish? The goal is to determine the cause for the problem and plan a solution. If the problem is increased denials, a reason has to be determined as to why this is happening. If the problem is increased A/R days, this could be attributable to denials or slow payors.
3. Research/gather data: What is the frequency, severity, and source of the suspected problem/concerns? After data collection for 30 days, it has been determined there is an increase in denials by 20 percent compared to last year. After an analysis of the information it was determined human error is to blame since the patient insurance account numbers were entered incorrectly.
4. Implementation of corrective action: What was done? Employees were re-educated on the proper format of the patient account numbers.
5. Re-measurements/re-evaluation: Was the desired goal achieved or should alternatives be considered? The analysis was complete and a proper corrective action plan was instituted. This should be re-evaluated in approximately six months to ensure the denial rate has not increased.
6. Identification, analysis, and implementation of any additional corrective actions: If the original corrective action did not resolve the problem, what is the next step? Further corrective actions will be determined if the primary action does not correct the problem.
7. Conclusion: The results of the study are evaluated and a conclusion is reached. Results are reported as appropriate. The problem was human error and this study enlightened the business office on the intricacies of attention to detail when dealing with insurance information.

Pathology

A lost specimen could be catastrophic for a patient if a test is being performed to diagnose a terminal illness. The purpose of the study is to determine if there are potential flaws in the submission and transportation of pathology specimens. If a specimen was lost from the point of origin to the pathology lab, this could be disastrous for the patient and the facility. A study should be completed that involves all parties with a part in this process. The pathway should be drawn to show the track a specimen will take from removal to the pathologist. All variables should be included that may affect this outcome. Some variables could be the day and time of the collection, the courier, the nurse, the paperwork, etc. Once this pathway is drawn a determination can be made as to potential holes. When the potential for flaws is discovered, then a correction plan should be written. Where is the problem and who is directly involved in the problem? Could it require a log to be developed? Should each specimen be checked by a staff member and the courier to ensure the items sent are the items actually taken? The newly found flaw should be discussed with all the appropriate teams to come to a conclusion and an action plan.

It might require an overhaul of the current system and a new process could be developed. It could involve extra steps to ensure the specimen was logged by the responsible person involved, to the courier picking up the specimen and having to sign the log with specific items listed. The next step is to ensure the pathology report is received into the patient's chart and the physician notified of the results.

Equipment evaluations (forceps)

Sampling of tissue is important to obtain a good specimen to make a proper diagnosis. The purpose of the study is to ensure the best reusable forceps are being used for GI procedures. The study involved several factors such as the ease of maneuverability, ease of grasping, size of specimen, quality of specimen and failure rate. The current problem involves inadequate forceps that continue to break when used and the quality of the specimen. A blind study was organized that included forceps from five different companies. A questionnaire was also developed that was specific to the physician, nurse and pathologist. The physician's questionnaire asked about the ease of insertion of the forceps, the nurse's questionnaire asked about the ease of obtaining the specimen and the pathologist's questionnaire was to determine the size and quality of the specimen based upon the size and the cut edge of the specimen. Each forcep was numbered and the number of uses of each individual forcep was tracked. This was done to determine how many uses before the forcep would break. The fun part about this study is no one knew what forcep was being used, and this gave the most accurate feedback.

On each case a questionnaire was collected from all three parties for four weeks. All the measurements from the physician, nurse and pathology were analyzed. The failure rate was also measured for each of the five types of forceps. It was discovered that one company had consistent high marks for ease of insertion, ease of closing the device and the quality of the specimen. Other forceps did not have all high marks. One factor that played heavily was the failure rate. This was not considered a factor at the beginning but was the major determining factor during and after the study.

As the study was concluded it was apparent which forcep was the best, mainly because the others had a high failure rate. This same methodology could be conducted on video towers, trocars, sutures, gloves, etc., that are used in an ASC.

Cecum study

The purpose of the study is to determine if the cecum is reached during a colonoscopy. This study involves the evaluation performed by peer physicians and should be done annually to determine the accuracy of the physicians during a colonoscopy. This can be reported as a percentage and compared to benchmarked data of a successful colonoscopy reaching the cecum. To remove all bias, a blind study was performed. To do a blind study, this required a review of the actual pictures labeled as "cecum" and the reviewer must determine if the cecum was reached. Approximately 5 percent of the quarterly charts were gathered and the pictures that were labeled as cecum were numbered with a corresponding key and attached to a blank sheet of paper. The key would identify the physician for that particular picture which were coded as A, B or C. The pictures were placed randomly with a corresponding question number and the answer would either be "yes" or "no" as to whether the cecum was reached. The evaluation of the pictures was performed by three separate physicians and the rate of reaching the cecum was also compared to national averages. The results were coded by physicians and the results were tabulated and shared with the governing board. It was determined that all physicians were within the range of national averages. While this study proved to have a good outcome, it is important to repeat this annually.

When determining a physician's ability to reach the cecum it is important to remove all bias from this peer review to get an accurate result.

On-time starts

This study involves data collection that will determine the frequency a physician starts the procedure on time at an ASC. A form can be developed that lists each stopping point for the patients and the time will be written. Some stopping point areas would be front desk, pre-op, holding, OR, procedure start time, procedure end time and time of discharge with the arrival time of the physician. While this is a lot of data to collect, it can be very useful. With a copy of the daily schedule next to the timesheet, it will be easy to follow the day and see how many procedures were started on time according to the published schedule. If the majority of the cases are beginning after the scheduled time, this will allow an administrator to work with the physician and make him/her aware of the problem and try to work on a resolution.

Applicability

All of these studies can be performed in any single-specialty or multispecialty surgery center. The facts may be changed to personalize the studies but the method and purpose would remain the same. The initial study should be completed and discussed and the same study could be reviewed again in 6-12 months to determine if the problem is fixed or if the problem still exists.

This should be a consistent ongoing component of the quality and performance improvement committee. It shows the ASC is looking to find ways to improve their processes and decrease any errors, and there is no limit to the type of studies that can be done. It is also a good idea to enjoy the studies that have been selected and then have the comfort of closing the loop.

Learn more about Peninsula Surgery Center.

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