Ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs) aren't doing all they could to ensure patient safety, according to a from the Leapfrog Group.
"Despite the fact that so much surgery is done in outpatient and ambulatory settings, there is very little publicly available data about quality and safety," Leapfrog Group president and CEO Leah Binder said Friday on a phone call with reporters. "We believe families and loved ones deserve to have this information to make informed decisions."
The Leapfrog Group, a 19-year-old nonprofit focused on patient safety and quality issues, surveyed 321 ambulatory surgery centers and 1,141 hospital outpatient departments about some of their patient safety practices. Current survey data only include aggregate numbers, although data on specific centers will be available in the next round of surveys starting in 2020.
In terms of ownership, 38% of participating ASCs represented a joint venture among physicians and a management company, while 29% were owned by either a single physician or multiple physicians, and 18% were owned by a combination of physicians and/or a hospital joint venture. The remaining 15% had other ownership structures.
Board certification was one issue of concern identified by the researchers. The survey found that in both ASCs and HOPDs, 65% of all individuals performing procedures were board-certified, as were 83% and 71%, respectively, of those administering anesthesia in HOPDs and ASCs.
"The problem in ambulatory surgery is many events that are truly catastrophic -- or even that cause minor to moderate complications -- are rare, although certainly with increasingly complex patients and procedures, they will be increasing in the future," said Lee Fleisher, MD, an anesthesiologist at the University of Pennsylvania in Philadelphia, and chair of Leapfrog's Ambulatory Surgery Center/Hospital Outpatient Department Expert Panel.
"Patients should be informed that they should ask if their anesthesiologists and surgeons are either board-certified or board-eligible ... [Otherwise], experts who are available to treat true complications may not be present in the facility, so we did feel this is an important structural measure to assess," Fleisher noted.
Hand hygiene was another area of concern. The survey showed that while nearly all ASCs and HOPDs used direct observation to see whether hospital staff was following good hand hygiene practices, no ASCs and only 6% of HOPDs were using electronic monitoring.
"One shortcoming with direct observations is that you are limited in the number of observations you can do," said Missy Danforth, vice president for health care ratings at the Leapfrog Group. In addition, "we're seeing that there are some gaps in HOPDs and ASCs having a system in place for initial and recurrent training and validation. You can imagine as new staff are brought on, it's incredibly important they're trained appropriately in hand cleaning to prevent different kinds of healthcare-associated infections."
The Leapfrog Group also found a low result for electronic monitoring when it surveyed inpatient hospitals, "which was surprising and, disappointing, frankly, because it's a way of monitoring 100% of interactions with patients and that's important, given the importance of hand hygiene to every single patient every minute of the day," Binder said.
In addition, only 53% of ASCs and 69% of HOPDs said they held their leadership accountable for their facility's maintenance of good hand hygiene. "For those most important aspects of patient safety like hand hygiene, it helps if the leadership is held accountable in some way, either through annual performance reviews or compensation," said Danforth.
As far as patient experience was concerned, ambulatory surgery centers performed slightly better on measures of patient satisfaction; for instance, 87% of ASC patients gave the facility the highest possible overall rating, versus 83% of HOPD patients. However, fewer ASCs were distributing patient satisfaction surveys, Danforth said. "We'd encourage more ASCs to administer the survey to their patients." In addition, 86% of ASC patients surveyed said they would recommend the facility to others, versus 82% of HOPD patients. ASCs and HOPDs scored virtually the same on other measures such as quality of facilities and staff, and what patients should do if they notice signs of infection following their procedure.
Information about what to expect during recovery is a critical component for patients, Fleisher noted. "Many facilities do not call patients 24 hours [after the procedure]," he said. "Discharge instructions are frequently lost within 10 to 12 hours ... We found a very high incidence that patients had a phone number, but the ability to re-set expectations if they have questions, or potentially learning of complications and how to get the centers to perform even better would be better achieved by contacting patients at that 24-hour mark."
One thing the group found most surprising was the answer to the question in the survey about whether or not ASCs and HOPDs were using a "safe surgery checklist," Danforth said; the survey found that 3% of ASCs and 4% of HOPDs do not use such a checklist.
"Safe surgery checklists have been a buzzword for a long time," and although the Centers for Medicare & Medicaid Services has stopped asking about the checklist in its quality reporting programs because the measure was "topped out" and everyone was doing it, "we found that not everyone's doing it," said Danforth. "We're going to look to making those questions a little more robust next year. We think it's the patient's 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 they're going to be kept safe, and there is a lot of evidence that the safe surgery checklist can do that."