How to remedy the top deficiencies I find in ophthalmic ambulatory surgery centers

As an ASC owner, you know how important it is to maintain compliance with state, federal and accrediting body regulations and standards. A deficiency discovered during a survey can eat up a tremendous amount of staff time in correcting that deficiency and proving continued compliance. So, rather than be on the defensive, go on the offensive when it comes to compliance.

To help you, I’ve compiled common ASC deficiencies that my colleagues and I see when performing mock surveys to gauge a facility’s “survey readiness.” I hope our findings — gathered from hundreds of ophthalmic ASCs and multi-specialty ASCs that perform ophthalmic surgical cases — can help guide your compliance efforts in the new year.

THE CHALLENGES

1. History and physical examination (H&P) missing for YAG laser patients.

Remember that the same requirements for surgical cases are in place for YAG laser patients. A current H&P, with an immediate preoperative note to ensure any updates to the H&P, is required.

2. Lack of discharge order on laser patients.

All patients in an ASC are required to have a discharge order by the physician. To ensure it doesn’t get overlooked, you can have the following statement on your preprinted orders: “Discharge home with responsible party once discharge criteria is met.”

3. Lack of a ride home with a responsible adult for laser patients.

All patients in an ASC are required to have a ride home with a responsible adult, per CMS. If there is an exemption for an individual patient, the physician must document why. An exemption cannot be made for a class of patients such as all YAG laser patients. If the physician desires to make an exemption for a particular patient, we recommend a physician’s order with the reasoning mentioned.

4. Lack of appropriate disinfection of YAG lens.

Recently, we have seen many deficiencies based on staff not following instructions for use (IFUs) for the disinfection of the YAG lens. Ensure your staff follow IFU guidelines to maintain compliance.

5. Lack of action if temperature and humidity are out of range in the operating room (OR).

The temperature and humidity in your OR, procedure room and sterile processing and sterile storage areas must be logged every day. If a recording is out of range, there should be an action column on your form — document the action taken and if it was effective.

Should the issue persist, you must consider doing a risk assessment and determine if you can continue to do cases in the affected room. Factors to consider are supply integrity, equipment function, infection risk and fire risk.

6. Inadequate sterile processing of ophthalmic instruments.

It is imperative that manufacturer IFUs are followed for decontamination and sterilization of all instrumentations and equipment. We recommend maintaining a copy of each instrument’s, ultrasonic’s, washer’s and sterilizer’s IFU. Your employees in the sterile processing department (SPD) must demonstrate that they follow each IFU. For example, if the sterilizer requires that a filter be changed weekly, they must create documentation showing it was done.

Remember that cleaning begins in the OR. Instruments should be wiped off and kept moist to get rid of bioburden. Decontamination and washing must occur per IFU. Ophthalmic instruments should be checked for issues through a magnifying lens.

7. Inadequate use of chemical and biological indicators during sterilization.

A chemical indicator should be used with each sterilizer run, and a biological indicator should be used at least weekly. You must be able to track a patient infection back through your SPD process to see if there was an issue with a particular tray. Remember that immediate use steam sterilization should not be utilized.

8. Gloves not worn on both practitioner’s hands when touching a patient’s eye.

Gloves should be worn any time the eye is touched. Also, gloves should be worn on both hands, not just one. This rule is for RNs administering drops and doing the eye prep as well as surgeons when doing blocks.

9. Life Safety Code (LSC) deficiencies.

Numerous LSC maintenance/tests need to be completed each day, month and year. Given that, we recommend your staff develop a compliance calendar to track the required items and ensure reports are obtained. Also, we recommend that you have a LSC engineer or expert conduct a specific life safety code mock in addition to a clinical mock survey.

10. Lack of 24-hour monitoring of medication refrigerator.

You must know the highs and lows of your medication refrigerator even on days you are closed. This ensures the integrity of your medications should your electricity go out (though your medication refrigerator should be on the backup generator). The temperature range should be documented daily. If it is out of range, contact your pharmacy consultant to determine if there has been any affect to the medications.

11. Lapse in privileges for practitioners.

Your reappointments must occur prior to your current appointment period expiring. If your current appointment expires, you cannot perform privileges and must submit a new packet for consideration. Your appointment and reappointment dates must match the governing body’s meeting minutes date showing approval.

12. Lack of peer review.

You must also show peer review to grant reappointments to providers. This is more than a simple chart audit for signature completion. Use a standardized form for surgical and anesthesia peer review that asks about the appropriateness of both the procedure/anesthesia and the H&P/pre-anesthesia evaluation. This review should be performed randomly on all practitioners at an interval you determine. In addition, you must perform incident-based peer review on incidents such as transfers, infections and surgical complications.

13. Lack of orientation documentation for staff and physicians/anesthesia providers.

Ensure you have orientation lists that are completed when new staff are hired and physicians are initially appointed. Please be aware that your accreditation organization or state may have guidelines as to the timing of completion.

GOOD HEADWAY

These are the major issues we at Progressive Surgical Solutions often see in ASCs. Reviewing these items in your facility — and then taking corrective measures if needed — will allow you to make good headway toward compliance. OM

Debra Stinchcomb, MBA, BSN, RN, CASC, is a senior consultant with Progressive Surgical Solutions, a division of BSM Consulting specializing in ASC development and management. Ms. Stinchcomb has more than 36 years in the health-care industry.