ASCs Play an Important Role in Upholding Patient-Safety Goals

ASCs Play an Important Role in Upholding Patient-Safety Goals

By Kelly M. Pyrek

Michael Kulczycki

Continuous quality improvement (CQI) and total quality management (TQM) are more than two basic business management paradigms; they have direct application to healthcare and are more important than ever in today’s focus on patient safety. Healthcare quality can be described as simply doing the right thing, at the right time, in the right way, for the right person.¹ The concepts of CQI and TQM require healthcare professionals to recognize the need for continuous improvement in healthcare delivery, and making it an essential part of everyday clinical practice.² The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) suggests that healthcare professionals weigh the following factors that affect the care they provide: appropriateness, availability, continuity, effectiveness, efficacy, efficiency, respect and caring, safety and timeliness.³

“We will be more of an ongoing presence than we have in the past, much more top of mind, not an exam to be passed every three years, but more of an organizational conscience,” says Dennis O’Leary, MD, Joint Commission president.

Last July, in an effort to help JCAHO-accredited facilities embrace continuous improvement, the Joint Commission’s board of commissioners approved the 2004 National Patient Safety Goals (NPSGs). These goals include the six 2003 NPSGs and their accompanying requirements, and add one new goal with two requirements that focus on reducing the risk of healthcare-acquired infections (HAIs):

• NPSG 1: Improve the accuracy of patient identification.
• NPSG 2: Improve the effectiveness of communication among caregivers.
• NPSG 3: Improve the safety of using high-alert medications.
• NPSG 4: Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
• NPSG 5: Improve the safety of using infusion pumps.
• NPSG 6: Improve the effectiveness of clinical alarm systems.
• NPSG 7: Reduce the risk of healthcare-acquired infections.

It is JCAHO’s hope to raise awareness of patient-safety mandates in all healthcare settings, including ambulatory surgery centers (ASCs), which traditionally have enjoyed fewer adverse events and medical errors.

“The culture of patient safety is beginning to have impact, but it will still take time,” says Michael Kulczycki, executive director of ambulatory accreditation/business development for JCAHO. “Sentinel event data has been gathered since 1995, but it’s still a voluntary process, with estimates that only 5 percent of adverse incidents are being reported. Even with two alerts published concerning wrong-site surgery (in 1998 and 2001) events went up, not down.”

In July 2003, JCAHO issued its Universal Protocol for preventing wrong-site, wrong-procedure and wrong-person surgery, which draws upon, expands and integrates a series of existing requirements under the 2003 and 2004 NPSGs, and is applicable to all operative and other invasive procedures. The principal components include:

1. The pre-operative verification process
2. Marking of the operative site
3. Taking a time-out immediately before starting the procedure
4. Adaptation of the requirements to non-operating room settings, including bedside procedures.

The Universal Protocol is the product of a national summit on wrong-site surgery convened by JCAHO, the American Medical Association, the American Hospital Association, the American College of Physicians, the American College of Surgeons, the American Dental Association and the American Academy of Orthopedic Surgeons.

“This Universal Protocol asks healthcare organizations to set a goal of zero-tolerance for surgeries on the wrong site or on the wrong person, or the performance of the wrong surgical procedure,” says O’Leary. “These are occurrences which simply should never happen.” Kulczycki points out that compliance with the universal protocol is required by July 1, 2004, although elements of it are currently contained in the NPSGs.

“I am not aware yet of innovative measures facilities have taken to (enhance the protocol),” he says, “because the protocol requirements are pretty straightforward implementation steps. We have noted the example of the Kaiser Permanente healthcare system which requires implementation of the protocol, with non-compliance of the OR team ‘timeout’ resulting in suspension of OR privileges in the hospital setting.”

While clinicians bear the brunt of compliance with the NPSGs and the universal protocol, facility administrators and non-medical personnel can support their compliance with these initiatives, Kulczycki says. “It requires leadership commitment to NPSGs and the Universal Protocol, and surveyors do observe for this commitment as part of the current survey process. Also, endorsement of the protocol by more than 50 organizations (medical societies and professional associations including FASA and AAASC) will go a long way to supporting compliance.”

Kulczycki says that increased attention to NPSGs by both healthcare consumers and members of the healthcare trade media has helped draw attention to patient-safety issues. He adds, “There are increased requirements for adverse events reporting, mostly for hospitals, but also increasingly in ambulatory settings.”

In ASCs, Kulczycki says the Joint Commission closely monitors NPSG No. 4.

“There are no special considerations (for ASCs),” he adds. “In fact, greater education is needed in ambulatory care settings, especially for wrong-site surgeries, since it applies both in operative and invasive procedures as well, extending its application well beyond ASCs and office-based surgery practices.” He says the JCAHO board has recognized the uniqueness of each accreditation program, and has called for a two-phase implementation of program-specific elements to NPSGs. In addition, a goal/requirement applicability grid is being developed for some of the accreditation programs, including ambulatory, to aid organizations in determining its application. For example, not all goals will apply in the ambulatory diagnostic settings (e.g., sleep labs or imaging centers). Kulczycki says that Phase II, with applicability by 2005, enables each program to recommend development of program-specific, evidence- or criteria-based goals unique to each program. These goals will be recommended to the Sentinel Event Advisory Group, charged with approving all changes to NPSGs, with final board approval and announcement to the field in July 2004 for 2005 implementation. An example for ambulatory facilities may be the addition of surgical fires, previously reviewed as Sentinel Event Alert No. 29 in June 2003. So, the future goals may result in core goals for all programs, and one or two goals specific for each program.

Kulczycki reminds healthcare professionals that JCAHO surveyors do not survey for adverse events; instead, they survey for compliance with ambulatory standards and with NPSGs, because the sentinel event database is a voluntary process.

“They do check for awareness — and implementation as appropriate — for sentinel event alerts issued in the last year,” he says. “Through the tracer methodology and staff and medical staff interviews, they do check for implementation of NPSGs. The tracer methodology, from surveys I’ve observed, really drives the point home to both staff and management as well as medical staff of the linkages between JCAHO standards and NPSGs and the impact on both operations (better performance) and improved patient safety. This is particularly impacted because the new process includes interviews with direct caregivers, including surgeons and anesthesiologists, as well as the physician owners.”

Kulczycki adds, “Tracer methodology truly tests the organization’s implementation of NPSGs, by both reviewing policy/procedures as applicable, but more important, asking a variety of caregivers, in non-structured and unplanned ways, for how the organization is implementing and demonstrating adherence to NPSGs. For example, in a survey observed last week in an endoscopy center, NPSG No. 7 was fully implemented as a new 2004 goal, but findings were reported on goals Nos. 1-6 because there was not a full year of implementation, given they were requirements all through 2003. The new process also encourages organizations to divulge such information, because the required follow-up by organizations (Evidence of Standards Compliance, with a four-month reporting of Measures of Success) is not onerous and easily complied with if the organization has met the standard.”

Beginning this year, JCAHO has been conducting unannounced surveys of accredited facilities to further underscore the need for continuous quality improvement.

“Unannounced surveys obviously will also aid compliance and help achieve 100 percent standards compliance, 100 percent of the time,” Kulczycki emphasizes.

The healthcare industry’s re-invigorated focus on patient safety has encouraged non JCAHO-accredited facilities to inquire about accreditation, and those facilities who have received JCAHO’s blessing in the past are seeking the agency’s continued stamp of approval.

“For 2003, for its ambulatory program, JCAHO has seen an increase of customers returning for resurvey, with nearly 80 percent of previous customers committing to stay with the process — a significant increase over budget for 2003),” Kulczycki says. “Also, a focus on patient safety, and its emphasis on patient care, does resonate better with prospective customers rather than simple standards compliance. Also, the new process focus on accreditation as a continuous process also helps, as well as shifting survey focus to processes which help the organization improve (systems tracers, and survey findings organized around ‘priority focus areas’).”

While there are no distinctive survey-result trends emerging yet, Kulczycki says, “JCAHO enables many start-up ASCs, or those new to the process, to use the early survey option, whereby it becomes a two-part survey. The first visit focuses on organizational structure and physical plant issues, with a follow-up survey four to six months later to focus on the patient experience. There seems to be an increase in organizations’ using this option.”

He recommends that facilities seeking JCAHO accreditation follow these simple steps:

• Become familiar with all JCAHO standards and NPSGs
• “Chunk it up” in terms of dividing up review of standards compliance (nine chapters and NPSGs), and the staff members responsible for them
• Create a timeline
• Use publications and live-education opportunities provided by Joint Commission Resources (JCR)
• Network with other facilities that have completed the survey process (for office-based surgery practices, the JCAHO ambulatory program offers “OBS Mentor Program” matching those new to the process to another practice willing to share their experiences)
• Consult the new standards manual for ambulatory settings (2004 CAMAC), which includes a standards scoring grid to self-evaluate organizational readiness
• Consult the Accreditation Manager Plus, a new electronic product from JCR that includes both an automated standards manual (electronic version) as well as an electronic version of the Periodic Performance Review, suitable for both self-assessment and future submission of the PPR as required to JCAHO (resurvey customers only)

And once facilities are accredited by JCAHO, they are encouraged to promote their status to the community. “JCAHO’s previous campaign to encourage patients, ‘Speak Up,’was wildly successful and used by both accredited facilities and non-accredited facilities,” Kulczycki says. “Similar efforts are foreseen for organizational use of both a Universal Protocol poster as well as a consumer brochure available for organizational reprinting.”

Visit http://www.jcaho.org/accredited+organizations/
patient+safety/universal+protocol/wss_universal+protocol.htm/.

Healthcare professionals can watch a free video on the 2004 JCAHO survey process for ambulatory care organizations.

Streaming video is available in two formats from the JCAHO Web site at: www.jcaho.org/accredited+organizations/
ambulatory+care/survey+process/svnp_ahc_video.htm/. 

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