Bring Your ASC Policies Up to Snuff
These resources are key to compliance — and profitability.
BY BETH HURLEY, R.N., C.R.N.O., C.O.E.
As I ponder the fate of yet another ambulatory surgery center (ASC) troubled with regulatory issues and now fighting to remain licensed, I struggle to determine how they got into this situation and what other facilities can do to prevent themselves from being in similar straits.
I frequently hear the familiar complaint, "How can they do this to us? We give great patient care." But as we all know in the medical field, if it isn't documented, then it wasn't done. An ASC needs attentive management and consistent leadership. As this article will explain, the first step is to understand regulatory requirements and provide sound operations management.
Acronyms aplenty represent organizations that can serve as resources in the quest for better ASC performance. Addresses for their Web sites are listed in this article.
Meeting Regulatory Requirements
ASCs began to proliferate in the early 1980s and ophthalmic outpatient surgeries led the initial surge in growth. Many of today's ophthalmic ASCs have been in operation for almost 20 years. Inspections by state agencies, for state licensure and Medicare certification, have often been sporadic and infrequent. Indeed, some facilities have not been fully surveyed in the past 10 years.
This has led to apathy on the part of compliance with regulatory requirements — even though the requirements in many states have changed. Another frequent statement, "But we've always done it this way," is no longer an accepted excuse. The first step in proactive management is to know the rules and regulations; it is hard to follow the rules if you don't know what they are.
If you don't have a current copy of your state regulations, contact your local Department of Health Services. Many states have online access; some states are easy to find — for example, ASC operators in Texas can check out Texas requirements at www.dshs.state.tx.us/HFP/asc.shtm. If you don't know whom to contact, find your local state agency contact information at www.cms.hhs.gov/SurveyCertificationGenInfo/Downloads/State_Agency_Contacts.pdf.
The next step is to find the CMS Conditions for Coverage. The State Operations Manual contains Appendix L: Guidance to Surveyors: Ambulatory Surgical Services. This document is issued for use by the surveyor and identifies the key items that are part of the survey process. It is an excellent tool to ensure that, as an ASC manager, you are looking at the same items for compliance. Appendix L can be found at www.cms.hhs.gov/manuals/downloads/som107ap_l_ambulatory.pdf. Be aware that CMS has recently made changes in regards to the conditions of coverage — the final rule was published in the Federal Register on Oct. 30, 2008. In order to keep up with CMS regulations and reimbursement issues, add www.cms.hhs.gov/center/asc.asp to your favorite Web sites.
Bring Staff Up to Speed
The nursing shortage has led to a significant increase is nurses' salaries and a decrease in nurses with operating room and management experience. Many of today's ASC administrators, directors of nurses and facility staff have been on-the-job trained. The difficulty with this is that "they don't know what they don't know."
It is essential to have detailed job descriptions to ensure that all the requirements of operating a facility are addressed. It is equally important to have a competency checklist to ensure that ASC staff members know, and are able to fulfill, the responsibilities of their job descriptions.
Staff competencies must include not only tasks, but knowledge of equipment as well. It is essential that they know where emergency equipment is located and how to use it — for example, the code cart and defibrillator or AED. It is then critical that they are given the opportunity to demonstrate and use those competencies by conducting mock drills such as code arrest or disaster drills. Staff must be held accountable for those responsibilities.
As much as we all dislike doing employee evaluations, this is the appropriate tool to use to ensure the competent management of your ASC. Be sure to take the time to know what motivates your employees; although money is the most frequently used tool, sometimes just remembering to thank your staff or providing a staff appreciation lunch goes a long way.
The Association of Operating Room Nurses (AORN), whose Web site is www.aorn.org, offers an Ambulatory Surgery Administrator Certificate Program. AORN also has an Advanced Program in this area. In addition, AORN has a program that can supplement the on-the-job training of nurses in the operating room; the Peri-operative 101 course. CASA: Certified Administrator Surgery Center (www.aboutcasc.org) provides the opportunity to demonstrate the knowledge needed to manage an ASC and certifies those that pass their test.
The Value of ASC Organizations
Because many ASCs operate in isolated or rural areas, it is beneficial to belong to at least one of the many professional ASC organizations. Participation is these organizations provides opportunities for networking with other leaders. The Outpatient Ophthalmic Surgical Society (OOSS), whose Web site is www.ooss.org, is dedicated to issues regarding ophthalmic ASCs, including advocacy, benchmarking and educational opportunities.
Another professional organization that addresses multispecialty ASC issues is the ASC Association (www.ascassociation.org). Many states have a state association and participation allows facilities to interact with other local ASC administrators to address state issues — for example, the Arizona ASC Association has bi-annual educational meetings and has hired a lobbyist who reviews state legislative activities that might have an impact on ASCs. One way to meet other ophthalmic ASC leaders is through joining the American Society of Ophthalmic Administrators (ASOA), at www.asoa.org, or through membership in the American Society of Ophthalmic Nurses (ASORN), whose Web site is www.asorn.org. Each of these organizations provides valuable information that will assist in the management of your ASC.
One way to ensure compliance is to proactively seek accreditation from an accrediting agency with "deem" status from Medicare. There are several organizations with deemed status; the three most common to ophthalmic ASCs are: Accreditation Association for Ambulatory Health Care (AAAHC) at www.aaahc.org; Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) at www.jointcommission.org, and the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) at www.aaaasf.org.
Most surveyors from these organizations tend to be consultative rather than punitive if your facility has made an aggressive attempt to comply with their requirements. Even if you choose not to be accredited, their standards manuals will be a valuable tool to ensure that your facility knows the requirements and is striving to meet them. There are also several states that are recognizing accreditation in lieu of a state survey for ASCs. They include Arizona, Arkansas, Florida, Georgia, Nebraska, Nevada, Ohio, Rhode Island, Texas and Wyoming.
Governance
If you haven't looked at your Medical Staff Bylaws and Governing Body Bylaws lately, be sure to review them. Do your credentialing requirements include reports from the National Practitioner Data Bank (NPDB), the American Medical Association (AMA) and the Office of Inspector General (OIG) for CMMS sanctions? Is there a defined process for handling an impaired physician? Is there immunity from liability? Are the responsibilities of the Governing Board and the Administrator clearly defined? Are the Governing Board meeting minutes up to date and do they accurately reflect the responsibilities of the Governing Board?
Total Quality Management
An ASC may have a number of different committees with a multitude of different names — Continuous Quality Improvement (CQI), Quality Assurance (QA), Risk Management, Infection Control, Peer review — that all relate to the improvement of the quality of care rendered in your facility. In an ASC where the same people are involved in the process of assuring quality of care, it makes sense to roll all committees into one program — the Total Quality Management (TQM) Program. The TQM program links quality improvement activities, facility operations, benchmarking, risk management and peer review activities into one meeting on a quarterly basis.
Benchmarking, as part of the TQM program, has proven to be an effective management tool that enables a business to identify opportunities for improvement by evaluating key indicators.
There is only a narrow margin between an average-performing ASC and a top-performing ASC. Benchmarking is a proactive way of monitoring clinical and financial statistics and is vital to effective ASC management. One of the great membership benefits of belonging to OOSS is that they provide an excellent way to benchmark your ophthalmic ASC against other ophthalmic ASCs of the same size, volume and ownership structure.
The Total Quality Management Committee should submit their meeting minutes to the facility's Governing Board quarterly. This ensures that the Governing Board is informed and can communicate the findings to the appropriate personnel.
Additional Resources
Be sure to take advantage of additional educational resources that are provided free of charge. For example, most professional liability insurance carriers will come into the facility and review operations and documentation but they will expect you to make corrections for any deficiencies found.
The Ophthalmic Mutual Insurance Company (OMIC) offers guidance on what ASCs can do to meet requirements for OMIC insurance coverage. Check out the following links:
■ Anesthesia and Sedation Risks and Precautions: www.omic.com/new/digest/Digest_SummerFall_04_v9.pdf
■ Minor Distractions Lead to Major Problems in the OR: www.omic.com/new/digest/DigestSummerfin.pdf
■ Emergency Equipment Requirements for Coverage with OMIC: www.omic.com/products/bus_products/downloads/OSF%20requirements.rtf
And be sure to check the following basic regulatory requirements, as these areas are where errors frequently occur:
► informed consent must include consent, not only for the surgical procedure, but for anesthesia as well
► credentialing must include privileging for all procedures, as well as for the administration of propofol (or any drug that does not have a reversal agent) and the supervision of R.N. administering IV conscious sedation
► compliance to the JCAHO "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery," found at http://www.jointcommission.org/PatientSafety/UniversalProtocol/
► follow-up on patients whose surgery was canceled, were transferred to another healthcare facility or who had complaints.
Know When to Seek Help
It's time to seek outside help if…
► your facility has more than four deficiencies with a state or Medicare survey, it is an indication that your management staff needs additional education, time or support.
► your facility fails a follow-up survey
► you can no longer find your Policy and Procedure Manual, Quality Assurance Program or Medical Staff credentialing files
► no one in the facility knows the rules and regulations that apply to your facility, get outside assistance immediately.
There are many ASC consultants that can provide assistance with these issues.
Finally, it is essential to be a great communicator. Keep everyone informed; make sure that staff members know that they can always expect the truth. Provide information and support so the staff feels like part of the team and can carry on without personal supervision. Dealing swiftly with small annoyances can reap great rewards in building trusting relationships with the medical staff and employees, as well as preventing long-term frustrations. This also assures everyone that the facility is in touch with the details and makes it a high priority to correct processes and improve efficiencies. OM
| Beth Hurley, R.N., C.R.N.O., C.O.E., is a principal with Innovative Surgical Resources in Phoenix, Ariz. She can be reached via e-mail at HurleyBeth@aol.com |
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