Watchdog Group Finds Safety/Quality Gaps in Outpatient Surgery Centers

Marcia Frellick

October 22, 2019

Outpatient, same-day surgery centers across the United States differ on training of providers and staff, communication with patients, and several key quality and safety measures, according to a report released today by the nonprofit watchdog organization The Leapfrog Group.

Researchers collected information for two surveys on the measures for hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs). The results are aggregated this year nationally, but after next year's survey they will be available by facility, according to Leapfrog's president and chief executive officer Leah Binder, MA, MGA, so that patients, providers, and payers can compare them.

"The decision on where to have surgery is enormously impactful in a person's life. It is extraordinarily important that they know about the safety and quality of the center where they are seeking that care," Binder said in a press briefing.

By August 31, 1141 hospitals and 321 ASCs had responded to the surveys. Binder notes that others have until November 30 to submit information to the website.

Not All Providers Are Board-certified

One gap was found in percentage of providers who were board-certified.

In ASCs, 71.3% of people who perform anesthesia are board-certified compared with 83.4% in HOPDs.

When asked whether all providers performing procedures in the facility were board-certified, only 64.5% of ACSs and 64.9% of HOPDs answered yes.

"Board certification is a designation that demonstrates expertise in a specialty area and it's one of the things that can signal consumers in particular that their physicians have the right experience. We really want to be moving toward 100% in these areas," Missy Danforth, vice president of healthcare ratings for Leapfrog, said in the press briefing,

She added that another surprise in the findings was that some outpatient surgery facilities are not using safe-surgery checklists.

She noted that the Centers for Medicare and Medicaid Services has removed that question from the ASC quality reporting program and the hospital outpatient quality reporting program because it appeared it was engrained in practice.

But these surveys indicate it is not universal.

"We think it is a patient expectation that when they go in for a procedure in any of these settings the surgical team is doing everything they can to make sure that they're going to be kept safe and there's certainly a lot of evidence that the safe surgery checklist can do that," Danforth said.

Anesthesiologist Lee Fleisher, MD, with the University of Pennsylvania Perelman School of Medicine in Philadelphia and chair of Leapfrog's expert panel on this subject, agreed in the press briefing that that finding was surprising. He noted that although only 3% to 4% said they didn't always use a checklist, "that's from a voluntary sample who were willing to actually say they didn't think it was important or didn't do it routinely."

Parents Should Ask About Advanced Life Support

The surveys asked the facilities if they always had a clinician certified in advanced cardiovascular life support and/or pediatric advanced life support (PALS) present when patients are having procedures or are recovering from them.

Almost all had them for adult life support, but only 88.6% of ASCs and 96.2% of HOPDs with pediatric patients said they always had a PALS-certified clinician present.

"This displays a gap in ability to perform life-saving actions if complications arise for pediatric patients," the authors note in the report, pointing out that parents should ask ahead of time if such clinicians will be present.

Few Monitoring Hand Hygiene Mechanically

Leapfrog leaders called the findings on hand hygiene "disappointing."

No ASCs and only 6% of HOPDs reported using mechanical monitoring. Almost all in both categories reported that they rely on direct observation.

Only 75% of ASCs and 66% of HOPDs had a system in place to regularly train clinicians on and validate hand-washing procedures.

Accountability was also lacking.

"For those most important aspects of patient safety like hand hygiene — it helps if leadership is held accountable in some way either through annual performance reviews or even compensation. Only 53% of ASCs report their leadership is held accountable in this area and 69% of hospital outpatient departments," Danforth said.

Consents Often Being Taken Same Day

Researchers asked when consents were being solicited for the surgeries and most of the ACSs (64.8%) and nearly half of the HOPDs (48.7%) said the day of the surgery.

Only one in seven of the ASCs (14%) and 20% of the HOPDs said they ask 1 to 3 days in advance.

"Many times the day of surgery, patients may be nervous," Danforth noted. "It's really best you have some advanced notice to review this information and ask questions."

The surveys were developed with guidance from Leapfrog's national expert panel and the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, according to a Leapfrog news release. They include standardized, evidence-based measures of care specific to locations that perform outpatient and ambulatory procedures.

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