It's essential for an ambulatory surgery center to keep its schedule full and its physicians busy in order to be profitable. Because of this busy atmosphere, centers need to implement checkpoints and processes to ensure everything runs smoothly and nothing is overlooked.
Michael Kulczycki, executive director of the Ambulatory Care Accreditation Program of The Joint Commission, and Steven Gunderson, DO, CEO and medical director of the Rockford Ambulatory Surgery Center, discuss six oversights that can cause complications in an ASC.
1. Physicians forgetting to add additional procedures to the consent form. Dr. Gunderson says extra procedures, such as a mole removal or hernia repair, are sometimes added to a surgery plan during the consultation between the surgeon and the patient. Oftentimes, these procedures are not added to the consent form.
Removing a mole is not a risky procedure, but the patient still needs to give consent for the procedure to be performed, he says. Oftentimes, it's these small, seemingly harmless add-ons that get missed. This opens the center up to legal liability if anything goes wrong. In addition, failing to obtain consent can result in the patient having to schedule another appointment.
If relatives are present at the center, the staff can check with them, Dr. Gunderson says. However, if the patient is alone and the procedure is potentially risky, such as a hernia repair, the surgeon will not be allowed to perform the extra procedure. Although Dr. Gunderson says it's hard to prevent such an oversight, he recommends ensuring that surgeons are aware of exactly what appears on the consent form.
2. Skipping the time-out before a procedure. The pre-operative time-out was implemented in the Joint Commission's wrong-site surgery program called the Universal Protocol. The time-out is an industry-accepted method for trying to reduce wrong-site surgery and other surgical errors, Mr. Kulczycki says. It was among the top 10 areas for non-compliance, as measured by the Joint Commission for accreditation, in 2008, 2009 and 2011.
A time-out should confirm the patient's identity, the correct procedure and site as well as ensure all equipment, implants and devices are correct. The surgeon should call the time-out, but in order for a time-out to be successful, every member of the surgery team needs to be involved.
"Calling for the time-out should be the responsibility of the surgeon," Mr. Kulczycki says. "They're the last person who's going to do anything before they lift that scalpel."
3. Sending lab work to a facility the patient's insurance does not cover. Dr. Gunderson and his director of nursing, Mary Beth Barich, say their center sends lab work to the same lab for processing unless a patient stipulates otherwise. Oftentimes, a patient's insurance will require lab work to be processed at a specific lab in order to be covered and will not cover the lab work done by the center's lab. This has been a constant struggle for the center, and patients are often shocked when they receive the bill for lab work.
The staff has created a form stating the patient understands the lab work will be sent to the center's default lab and are responsible for the cost if it is not covered by insurance. The form also includes a section where patients can specify which lab they want their lab work sent to. The form is included with the registration forms when the patient first arrives.
4. Improper labeling of drugs. Mr. Kulczycki says improper drug labeling has been a top non-compliance issue for the past four years: It was number one in 2008, number two in 2009 and 2010 and tied for number three in 2011. Improper labeling can result in the patient receiving the wrong dose of a drug, an expired drug or the wrong drug.
Mr. Kulczycki recommends enlisting the center's pharmacist, who may be employed on a contract or part-time basis, to do a walkthrough of the center's drug storage area. Because of their knowledge of the drugs, pharmacists can spot errors quickly.
"You're already paying them, but you should take full advantage of their knowledge," he says.
5. Not credentialing and privileging physicians. Credentialing refers to granting a physician the right to practice at a facility, and privileging indicates which procedures that physician is allowed to perform. Joint Commission surveyors often find centers are not up to date on credentialing and privileging their physicians, Mr. Kulczycki says. The most commonly-missed step is checking the National Practitioner Data Bank. The Data Bank tracks claims made against physicians, such as adverse peer review actions and medical liability settlements as well as professional society memberships.
Keeping up with the database has proven challenging for centers, Mr. Kulczycki says. A two- to four-room ASC might have 60-80 medical physicians on staff, and getting it right for all of them is demanding.
"What happens is they go through most of the procedural steps for reviewing and renewing their credentials and privileges, but because the National Data Bank requires them to go outside [their center's information], they don't do it," he says. "They know what they need to do, it's just not done."
Mr. Kulczycki says keeping track of credentialing and privileging is not hard but does require a detail-oriented person. He recommends keeping track of all the renewal dates in one location, such as an Excel spreadsheet.
6. Failing to wash in and wash out. The Joint Commission’s Center for Transforming Healthcare has also started an initiative to increase hand hygiene compliance and has developed a targeted solutions tool. Mr. Kulczycki says the tool is currently being used in 2,000 facilities — 15 percent of which are ambulatory centers or ASCs. When the project started, the hand hygiene compliance rate was 45-50 percent, but has risen to 75 percent after implementation of the disciplined steps as part of the tool.
While staff and surgeons generally remember to wash in before a procedure, they may fall short remembering to wash out after a procedure, Mr. Kulczycki says. The tool is available to all Joint Commission accredited centers.
Related Articles on Quality and Infection Control:
Closing the Quality Gap: National Initiatives & Action Steps for Integrating Evidence Into Practice
FDA, Medical Instrumentation Group Identify 7 Medical Device Reprocessing Priorities
How to Clean a Surgery Center's OR According to AAAASF Standards
Michael Kulczycki, executive director of the Ambulatory Care Accreditation Program of The Joint Commission, and Steven Gunderson, DO, CEO and medical director of the Rockford Ambulatory Surgery Center, discuss six oversights that can cause complications in an ASC.
1. Physicians forgetting to add additional procedures to the consent form. Dr. Gunderson says extra procedures, such as a mole removal or hernia repair, are sometimes added to a surgery plan during the consultation between the surgeon and the patient. Oftentimes, these procedures are not added to the consent form.
Removing a mole is not a risky procedure, but the patient still needs to give consent for the procedure to be performed, he says. Oftentimes, it's these small, seemingly harmless add-ons that get missed. This opens the center up to legal liability if anything goes wrong. In addition, failing to obtain consent can result in the patient having to schedule another appointment.
If relatives are present at the center, the staff can check with them, Dr. Gunderson says. However, if the patient is alone and the procedure is potentially risky, such as a hernia repair, the surgeon will not be allowed to perform the extra procedure. Although Dr. Gunderson says it's hard to prevent such an oversight, he recommends ensuring that surgeons are aware of exactly what appears on the consent form.
2. Skipping the time-out before a procedure. The pre-operative time-out was implemented in the Joint Commission's wrong-site surgery program called the Universal Protocol. The time-out is an industry-accepted method for trying to reduce wrong-site surgery and other surgical errors, Mr. Kulczycki says. It was among the top 10 areas for non-compliance, as measured by the Joint Commission for accreditation, in 2008, 2009 and 2011.
A time-out should confirm the patient's identity, the correct procedure and site as well as ensure all equipment, implants and devices are correct. The surgeon should call the time-out, but in order for a time-out to be successful, every member of the surgery team needs to be involved.
"Calling for the time-out should be the responsibility of the surgeon," Mr. Kulczycki says. "They're the last person who's going to do anything before they lift that scalpel."
3. Sending lab work to a facility the patient's insurance does not cover. Dr. Gunderson and his director of nursing, Mary Beth Barich, say their center sends lab work to the same lab for processing unless a patient stipulates otherwise. Oftentimes, a patient's insurance will require lab work to be processed at a specific lab in order to be covered and will not cover the lab work done by the center's lab. This has been a constant struggle for the center, and patients are often shocked when they receive the bill for lab work.
The staff has created a form stating the patient understands the lab work will be sent to the center's default lab and are responsible for the cost if it is not covered by insurance. The form also includes a section where patients can specify which lab they want their lab work sent to. The form is included with the registration forms when the patient first arrives.
4. Improper labeling of drugs. Mr. Kulczycki says improper drug labeling has been a top non-compliance issue for the past four years: It was number one in 2008, number two in 2009 and 2010 and tied for number three in 2011. Improper labeling can result in the patient receiving the wrong dose of a drug, an expired drug or the wrong drug.
Mr. Kulczycki recommends enlisting the center's pharmacist, who may be employed on a contract or part-time basis, to do a walkthrough of the center's drug storage area. Because of their knowledge of the drugs, pharmacists can spot errors quickly.
"You're already paying them, but you should take full advantage of their knowledge," he says.
5. Not credentialing and privileging physicians. Credentialing refers to granting a physician the right to practice at a facility, and privileging indicates which procedures that physician is allowed to perform. Joint Commission surveyors often find centers are not up to date on credentialing and privileging their physicians, Mr. Kulczycki says. The most commonly-missed step is checking the National Practitioner Data Bank. The Data Bank tracks claims made against physicians, such as adverse peer review actions and medical liability settlements as well as professional society memberships.
Keeping up with the database has proven challenging for centers, Mr. Kulczycki says. A two- to four-room ASC might have 60-80 medical physicians on staff, and getting it right for all of them is demanding.
"What happens is they go through most of the procedural steps for reviewing and renewing their credentials and privileges, but because the National Data Bank requires them to go outside [their center's information], they don't do it," he says. "They know what they need to do, it's just not done."
Mr. Kulczycki says keeping track of credentialing and privileging is not hard but does require a detail-oriented person. He recommends keeping track of all the renewal dates in one location, such as an Excel spreadsheet.
6. Failing to wash in and wash out. The Joint Commission’s Center for Transforming Healthcare has also started an initiative to increase hand hygiene compliance and has developed a targeted solutions tool. Mr. Kulczycki says the tool is currently being used in 2,000 facilities — 15 percent of which are ambulatory centers or ASCs. When the project started, the hand hygiene compliance rate was 45-50 percent, but has risen to 75 percent after implementation of the disciplined steps as part of the tool.
While staff and surgeons generally remember to wash in before a procedure, they may fall short remembering to wash out after a procedure, Mr. Kulczycki says. The tool is available to all Joint Commission accredited centers.
Related Articles on Quality and Infection Control:
Closing the Quality Gap: National Initiatives & Action Steps for Integrating Evidence Into Practice
FDA, Medical Instrumentation Group Identify 7 Medical Device Reprocessing Priorities
How to Clean a Surgery Center's OR According to AAAASF Standards
