AAAHC Institute Releases Seven New Ambulatory Healthcare Reports

SKOKIE, Ill.-- Seven new reports by the AAAHC Institute for Quality Improvement (AAAHC Institute), a not-for-profit subsidiary of the Accreditation Association for Ambulatory Healthcare (AAAHC), offer insights to enhance the quality of some of the most common outpatient procedures. The reports range from addressing procedures that primarily affect the elderly (cataract surgery) to children (myringotomy), as well as mobility concerns (knee arthroscopy) and screening for one of the most common cancers (colonoscopy for colorectal cancer).

“The need for best-practices information in outpatient care is pressing, as an increasing proportion of all healthcare needs are met in ambulatory settings,” said Naomi Kuznets, PhD, managing director of the AAAHC Institute. “Our reports illustrate that excellent ambulatory patient care isn’t a function of volume or total spending. It is a matter of knowing certain practices and procedural efficiencies, and how to adopt them. One role of the Institute reports is to identify and promote practices that ambulatory healthcare professionals can use to provide a better experience to their patients.”

The seven new 2006 AAAHC Institute studies include:

-- Cataract Extraction With Lens Insertion

-- Colonoscopy

-- Knee Arthroscopy with Meniscectomy

-- Ambulatory Surgery Non-Clinical Study Report – Cataract Extraction With Lens Insertion

-- Ambulatory Surgery Non-Clinical Study Report – Colonoscopy

-- Ambulatory Surgery Non-Clinical Study Report – Knee Arthroscopy with Meniscectomy

-- Ambulatory Surgery Non-Clinical Study Report – Myringotomy, Initial Findings

Clinical reports include data such as pre-procedure, procedure and discharge time comparisons, operative techniques, complications, non-routine procedures, anesthesia, instrumentation and supplies and patient outcomes.  Non-clinical reports focus on factors such as type and ownership of facilities, staffing costs, billing and collections, supply management, annual spending, information technology and patient satisfaction.

Cataract Extraction with Lens Insertion

With more than 95 percent performed in an ambulatory setting, cataract and lens operations are the number-one outpatient surgical procedure. Two new AAAHC Institute reports offer data from ambulatory centers on clinical (70 survey participants) and non-clinical (67 survey participants) aspects of cataract surgery. Key clinical findings include:

§  The median pre-procedure time was 83 minutes overall (range 41 to 212 minutes). Practices followed by the organization with the lowest pre-procedure time include:

-- scheduling cases that are expected to be lengthier/more difficult at the end of the day, so as not to delay routine cases;

-- comparing scheduling with actual timing throughout the day;

-- increasing staff at pre- and post-op to promote better patient admission and operating start times;

-- having the instrument technician assist the scrub technician to set up and minimize the surgeon’s start time.

§  The use of multiple procedure rooms per surgeon was not associated with shorter surgery start to finish times.

§  Some organizations shifted patient wait times from the waiting area to the procedure room, but this practice still increases facility time and can hurt patient satisfaction levels.

§  More than half (56 percent) of organizations used standardized lens brand among all surgeons who perform cataract surgery, with prices ranging from $30 to $215 (medians from $55 to $150). For those that did not standardize lens brand, prices reported ranged from $14 to $848, with a median of $64.

§  Of 1,600 patients who responded to a questionnaire, 98 percent reported that their vision improved. Only 34 patients said their vision changed for the worse and of these, 13 reported that they needed to contact the physician or facility for an unscheduled visit. 

Some key non-clinical findings:

§  Methods used to control staffing costs included:

-- rotating staff and limiting overtime;

-- using part-time nurses and staggering nurses’ hours to align with the surgery schedule;

-- cross-training staff for tasks that don’t require healthcare training;

-- having well-established practicing registered nurses available to fill in for vacations or other time off.

§  Organizations with the lowest scheduling costs:

-- share business operations with their physician offices

-- have a direct line to medical trained, experienced schedulers

-- educate physician offices about needed information before they call the surgery center

§  The organization with the lowest supply costs uses bulk purchasing of items all physicians use, and buy specialty items from lower price vendors.

Colonoscopy

Colorectal cancer screenings are the second-most frequently performed procedures in ambulatory care, with at least 9.8 million performed annually, and the numbers are growing. Two new AAAHC Institute reports offer data on the clinical and non-clinical aspects of this field. Key clinical findings include:

§  More than three-quarters (77 percent) of 110 clinical study participants identified themselves as freestanding endoscopy centers and 15 percent as freestanding multi-specialty centers. Others identified themselves as office-based surgery organizations (5 percent), hospital outpatient departments (2 percent) and an ambulatory surgery center.

§  The annual volume of colonoscopy procedures ranged from 35 to 17,500.

§  The facility with the lowest reported procedure time (9.7 minutes) also found, removed and/or biopsied quite a few polyps on average (more that 6 polyps removed on average and nearly 7 abnormalities biopsied). This was considerably shorter than the average procedure time (16 minutes). The facility attributed its procedural speed to experienced nurses, a skilled technician and adequate sedation.

§  The median discharge time was 42 minutes (range 22 to 92 minutes). Facilities with lower discharges times partly attributed this to:

-- very rare (0.03 percent) use of reversal agents;

-- having one nurse stay with the patient from admission to discharge;

-- providing pre-procedure teaching for all patients, including information on  recovering from sedation at home;

-- reviewing discharge instructions when patients are fully awake and having a post-procedure snack;

-- encouraging a friend or family member to stay and be ready to take the patient home.

-- teamwork/good communication.

Non-clinical findings included:

§  The number of operating or procedure rooms per facility varied from one to 16, with a median of four rooms. The average number of daily cases per room was 6.5.

§  A median of 86 percent of supplies are standardized for organizations performing colonoscopy.

Knee Arthroscopy with Meniscectomy

Two new studies focus on clinical (25 survey participants) and non-clinical (39 survey participants) aspects of knee arthroscopy with meniscectomy.  Among clinical findings:

§  The three top indicators for this procedure were a positive MRI, painful popping and joint line tenderness.

§  Procedure times ranged from 14 to 41 minutes, with a median of 26 minutes. Facilities with lower procedure times attributed this to:

-- appropriate scheduling (not too long or short);

-- making every attempt to have all potentially needed equipment available;

-- maintaining a central area for efficient cleaning and processing of equipment;

-- surgeon skill and efficiency;

-- surgeons who specialize in this type of procedure and staff who do them daily.

§  Fourteen out of 549 patients contacted the doctor for possible post-operative complications and information due to: pain and swelling (3); bleeding (2); pain (2); drainage (1); heat/redness (1); leg cramp (1); medication (1); medication and pain (1); swelling (1); and post-operative nausea and vomiting (1).

Some non-clinical findings:

§  The vast majority of the 39 facilities participating in the non-clinical study (31) identified themselves as multi-specialty centers. Another six identified themselves as single-specialty centers, one as an office-based surgery organization and one as a specialty hospital.

§  The number of operating or procedure rooms per facility varied from one to 16 with a median of five rooms. The average number of daily cases per room was five.

Myringotomy

Most frequently performed on children, myringotomy with tympanostomy tube insertion involves tiny incisions made in the eardrum and insertion of tubes to drain excess fluid that can cause pain, infection or hearing problems. With more than 500,000 procedures performed annually, myringotomy is the most common pediatric, ambulatory operation performed in the U.S. Key findings of the new AAAHC Institute non-clinical study include:

§  Although the majority (19) of 24 organizations surveyed are at least partly surgeon-owned, an equal number of myringotomy procedures were performed by owner-surgeons and non-owner surgeons.

§  Half of the organizations surveyed had 6 or more procedure rooms.

§  Five was the median number of daily cases per procedure room.

§  The median annual supply cost for participating organizations was $1,076,845.

§  93 percent of patients said their procedures were scheduled as soon as they wanted.

§  100 percent of patients were satisfied with the organizations’ respect for what they had to say and concern for their comfort.

Organizations that participated in the AAAHC Institute studies were predominantly multi-specialty facilities; all were volunteers that had opted to participate in previous AAAHC Institute studies and/or were accredited by the AAAHC. Study results should not be used, nor were they designed, to assign “relative values” to processes and outcomes or to set reimbursement policies. To order copies of the reports or for more information, visit the AAAHC Institute online at www.aaahciqi.org.

The AAAHC Institute for Quality Improvement is among the few organizations to provide ambulatory care providers with opportunities for benchmarking on a national level. The Accreditation Association established the AAAHC Institute in 1999 to provide ambulatory healthcare organizations opportunities to participate in quality improvement and performance measurement studies and educational programs. To date, the AAAHC Institute has conducted and published 36 performance measurement studies and has convened annual national forums on quality improvement in ambulatory healthcare.  Involvement in clinical performance measurement is a signal to patients, government agencies, professional liability insurers, and third-party payers, that an ambulatory health organization is committed to continually improving the care it provides to its patients.

Source: Accreditation Association for Ambulatory Healthcare (AAAHC)