ASC-01
Patient burn
ASC-02
Patient fall
ASC-03
Wrong site, wrong side, wrong patient, wrong procedure, wrong implant
ASC-04
Hospital transfer/admission
ASC-05
Prophylactic IV antibiotic timing
ASC-06
Safe site surgery checklist use
ASC-07
ASC facility volume data on selected ASC surgical procedures
ASC-08
Influenza vaccination coverage among healthcare personnel
ASC-09
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
ASC-10
Endoscopy/polyp surveillance: colonoscopy interval with a patient with a history of adenomatous polyps—avoidance of inappropriate use
ASC-11
[Voluntary reporting] cataracts—improvement of patient’s visual function within 90 days following cataract surgery
ASC-12
Facility 7-day risk standardized hospital visit rate after outpatient colonoscopy [21]
ASCs must be proactive in developing a comprehensive, ongoing QAPI program. The program must be data driven and show that the ASC is improving quality of care and providing a safe environment for the patient, visitors, and staff. The quality improvement program evaluates the processes in which tasks are carried out and identifies the potential for future process failures. Every member of the staff should be educated on how to identify a potential process failure and report the problem. In addition, all staff members need to be educated on how to evaluate a process for a potential failure or how to evaluate a process that has failed. The goal of the QAPI program is to be able to identify potential process issues before they actually have caused patient harm. While it is generally accepted that most ASCs are excellent at collecting data, the real change happens when the ASC begins using the data collected to improve processes and decisions. Therefore, the key to a successful QAPI program is knowing how to use the data collected and implementing the correct changes.
Factors That Drive a Culture of Safety in an ASC
Building a culture of safety in an ASC is a team effort. The ASC is an environment where the staff members, physicians, guests, and vendors must all work together to provide safe, quality care for the patient. The ASC leadership team , overseen by the Administrator, runs the day-to-day operations. The Administrator is granted the authority by the Governing Board to oversee day-to-day operations and make decisions that impact quality and safety. CMS states that, “The ASC must have a governing body that assumes full legal responsibility for determining, implementing, and monitoring policies governing the ASC’s total operation.” The governing body has oversight and accountability for the quality assessment and performance improvement program , ensures that the facility policies and programs are administered so as to provide quality healthcare in a safe environment, and develops and maintains a disaster preparedness plan” [4].
Culture begins at the top and filters down to every employee, surgeon, and anesthesia provider working in the ASC. Lucian L. Leape, MD says, “Management must ‘manage’ for patient safety just as they manage for efficiency and profit maximization. Safety must become part of what a hospital or healthcare organization prides itself on” [5]. The mission of every ASC should be to encourage the sharing of knowledge freely; thus optimizing patient safety practices. The staff members must be empowered by leadership to speak up and support patient safety.
Typical characteristics found in ASCs that embrace a safety culture:
The team embraces patient safety goals and processes. They understand how to implement process and procedural changes that support the delivery of patient care [6].
The ASC team establishes a patient safety program that is well defined and supports communication. Communication should be clear and convey a strong commitment to safety. The ASC safety programs have well-defined objectives. The ASC should have at least one person dedicated to collecting and analyzing safety data. The data and suggested changes are reported through the QAPI Committee to the Medical Executive Committee to the Governing Board . The Governing Board must see and understand that the Quality and Safety program are essential to patient care. The Governing Board must provide the resources needed to maintain the program [6].
The ASC team willingly discusses patient safety . Team members seek out the means to assure communication is appropriate and enforce the ASC’s goals addressing patient safety. Team members feel they are valued and respected when they speak up. Team members actively encourage patients and family members to participant in patient care [6].
The ASC is transparent and discloses to the patient and family what error(s) was made and the potential consequences of the error. Embracing transparency is woven into the ethical and moral responsibility of the ASC organization. The ASC leadership team communicates to the Governing Board errors and other safety problems. The Governing Board provides support to the team to resolve the problem and provides resources to prevent further errors.
The organization promotes a blame-free environment.
Typical characteristics found in a blame-free environment:
The organization embraces the concept that most errors occur as a result of flawed systems or processes, not flawed people.
The ASC rewards the team for reporting of errors, near misses, and safety concerns.
The organization educates and reeducates its staff every time a process change is made.
Prevention of errors is one of the ASC’s key focus points.
Typical characteristics found in an ASC that focuses on safety:
The ASC is proactive in looking for ways to improve safety in every process used in the center.
The ASC incorporates checklists, protocols, and defined work processes.
The ASC embraces the process of “hand[ing]-off” a patient from one caregiver to the next caregiver using a specialized handoff checklist.
The team encourages the patient to participate in the handoff by encouraging the patient to “speak up” if something said is not accurate.
Resolving conflict among caregivers is imperative to the culture of safety. If staff members are not trained to deal with conflict, then the environment has the potential to become toxic with characteristics such as bullying, gossiping, and sabotage becoming the norm. An ASC can be a high-stress area to work. The fast pace of work performed in an ASC creates an environment ripe for potential conflict. The staff needs to be taught how to deal with high-stress levels and to communicate their needs in a respectful manner. Leadership needs to be held accountable for recognizing issues early on and help the team members having a conflict deal with the issues openly and properly [7, 8].
Building a culture of safety takes an entire team and leadership must be actively involved and support the team. Everyone must be held accountable for their actions and decisions without resorting to the “blame game.” Policies and procedures must be written clearly and describe the how they will be met by the ASC staff. Safety should not be a topic that is only addressed quarterly when reports are due. Safety needs to be addressed in an ongoing fashion. Reviewing documents and processes, auditing for compliance to policies, and the use of checklists are essential for leadership to be able to identify gaps and address them in a timely before a safety issue actually occurs [9].
Quality Assessment Performance Improvement
A Quality Assessment and Performance Improvement (“QAPI”) program is the key to an ASC practicing safely. The Risk Management, Pharmacy, Safety and Infection Prevention committees report to the QAPI committee within an ASC. However, QAPI is only somewhat protected from discovery in case of a potential or actual malpractice suit or other lawsuit as some states do not honor the confidentiality of the QAPI process. Other states, including the federal government, see QAPI as important to improving patient care and solving problems and encourage ASCs to follow the process by allowing organizations to keep the information confidential. Some healthcare leaders feel that if the QAPI process is not held confidential, many healthcare facilities would not fully investigate or report problems. Without the investigation and reporting of problems, the ambulatory industry would be setup to make the same errors over and over again with the potential to harm patients. However, most facilities are afraid to share errors and lessons learned for fear the public would find out and competitors would use the information against them. If the ambulatory industry felt safe to share errors and potential solutions many more errors could be prevented.
CMS says, “The ASC must develop, implement, and maintain an ongoing, data-driven quality assessment and performance improvement (QAPI) program” [10]. The QAPI program must be proactive. In order to be proactive, the leadership team must provide time for the QAPI Coordinator and the QAPI committee members to meet, review, audit, and follow-up on issues identified. The committee needs to be provided space so that the group can hold confidential conversations, review and analyze data, make recommendations (solutions), and setup studies to test recommendations (solutions) to confirm the validity of the improvement that it provides a safer process.
The ASC’s Governing Board must identify QAPI priorities for the center. The priorities must focus on high risk, high volume, and problem-prone areas in the ASC such as the preadmission process where there is such a high volume of interviews performed. Then a preadmission process analysis is completed each month on the effectiveness of the interview process. The QAPI Committee could look at the analysis and see how many patients canceled on the date of service and how many patients were transferred to the hospital after surgery and why. The priorities set by the Governing Board must consider how often the ASC could experience an incident and the severity of the incident if experienced. The Governing Board is obligated to look at the potential patient outcomes, patient safety failure opportunities, and the quality of care the ASC is providing.
The QAPI Committee members need to be educated in conducting comprehensive audits, data analysis, and reviews of errors. If the facility leadership team neglects educating the QAPI committee members on how to be effective committee members, the result is a QAPI program that does not meet the CMS requirements for certification and does not promote patient safety. The key to a successful QAPI program is the committee members being proactive and taking their responsibilities seriously.
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