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Assessing Ambulatory Service Centers

 |  By Marianne@example.com  
   July 05, 2012

This article appears in the June 2012 issue of HealthLeaders magazine.

In just a few months, a patient may walk into an ambulatory surgery center, pull up the organization's quality metrics on his or her smartphone, and walk right back out.

That's because starting on October 1, 2012, a new Centers for Medicare & Medicaid Services rule created under the Patient Protection and Affordable Care Act will require any Medicare-eligible ASC to submit reports on five quality measures or face a 2% payment reduction. CMS has said it will publish surgical center quality scores as reported and risk adjusted on a new website, in the vein of Hospital Compare.

The initial five quality metrics are the number of 1) patient burns; 2) falls; 3) surgeries that are wrong site, wrong side, wrong patient, wrong procedure, or wrong implant; 4) surgeries requiring a hospital transfer or admission; and 5) the number of patients who did not receive an IV antibiotic within one or two hours before incision.

One year later, the list will include facility volume for some gastrointestinal, eye, nervous system, musculoskeletal, skin, and genito-urinary codes. And the year after that, the list expands further to the percentage of healthcare personnel who receive influenza vaccination.

Another 33 metrics are listed in the CMS rule as "under consideration" such as the extent of follow-up care a patient receives after leaving the center, visual loss, patient experience scores, certain measures governing cataract surgery, unplanned ICU admission, pneumothorax, systemic toxicity from local anesthetic, reintubation, anaphylaxis, transfusion reaction, and postdischarge emergency department visit within 72 hours.

Experts agree that, although this rule will cause major changes in the ASC marketplace, it will not drastically alter outcomes in the inpatient or outpatient setting.

Collecting the right data
"I believe the pay-for-reporting quality metrics will be good for our industry because it will raise the bar for all ASCs," says David Covert, CEO of Phoenix-based Banner Surgery Centers, which is part of Banner Health and has 10 outpatient surgery centers in Arizona, Colorado, and Nevada. "This ultimately benefits Banner Surgery Centers because we have carefully tracked our quality and patient satisfaction for years. In addition to our history of measuring performance, we also benefit from being part of a large system where we are encouraged to share best practices and benchmark against Banner hospitals."

Banner Surgery Centers track several Surgical Care Improvement Project indicators—hospital transfers and admissions, postoperative infections, patient falls, and patient burns. They also track patient satisfaction, on-time starts, turnover times, patient wait times, and employee sharps injuries.

"I think the new rule will improve the outcomes because I think when you begin to measure things you begin to improve them and the public begins to ask about the quality of the service you deliver," says Marlon Priest, MD, CMO of Bon Secours Health System, a $3.3 billion not-for-profit Catholic health system based in Marriottsville, Md. "[The data] is bit of a challenge to collect in some markets, but if you look at the list it will improve the outcomes."

Bon Secours surgical centers already track the five quality metrics that will be required this fall, but Priest says he is looking to focus on tracking clinical data rather than claims data.

"The problem we have with this is some of these pieces of data are from claims and it's not nearly as good as clinical data," he says. "We track clinical data on wrong-site surgery, antibiotics, and surgical infection rates—and there's a lot of work going on right now about how to reduce those or eliminate them."

At Catholic Health Partners, a Cincinnati-based 24-hospital healthcare system, the quality team uses a balanced scorecard that tracks operating efficiencies and quality metrics for ambulatory surgery. It also uses a Midas+ Solutions database consistent with what is collected for inpatients.

"We do expect the same level of quality and services in our ambulatory care centers as we do our inpatient surgical centers," says Marcia Messer, vice president of clinical transformation and nursing excellence. "We see the new metrics as contributing to consistency in quality outcomes and standard-of-care among inpatient and ASC settings."

Migrating procedures
As a result of the new rule, some wonder whether the industry will see a migration of increasingly risky procedures from the inpatient setting to outpatient facilities. But this migration has already begun, Priest says.

"I think we've already seen that, if you look at the procedures that were done in ambulatory centers in the past—going back eight or 10 years—and compare those procedures to what's done now," he says. "The complexity of the procedures will grow but the risk will be relatively low. When you get better in the hospital you can do it in the less monitored environment because we know how to mitigate the risk."

High case mix index patients will move to surgery centers, but the outcomes will continue to be very good because they don't move from inpatient to outpatient until physicians are comfortable to do it without all the resources in the hospital, Priest says.

For example, a gallbladder removal performed 20 years ago resulted in a large incision and a five- to seven-day hospitalization, plus another six to eight weeks of recovery, he says. But now, thanks to innovations like the laparoscope, the procedure can be done the same day.

"The same diagnosis has now moved from being a big long hospital stay to six or 10 hours," Priest says.

Catholic Health Partners also believes that technological advances and an increase of minimally invasive procedures will lead to a migration to ambulatory settings, but that riskier procedures will not move to ASCs.

"We have criteria we will continue to follow to ensure safety in that regard," Messer says. "For example, an elderly person with a high risk of complications would still receive procedures in an inpatient setting."

Covert agrees that at Banner Surgery Centers risky procedures will not prematurely move to outpatient facilities.

"Banner Surgery Centers have carefully established the parameters surrounding which patients can access our services," he says. "Physicians and clinical leadership carefully risk-stratify cases in support of this."

For example, over the past 10 years Banner Surgery Centers have been able to safely manage higher-acuity patients. The organization started out not working with patients with a BMI higher than 35. Later, it increased the maximum BMI to 40. Now, they defer to their medical director and the surgeon about what is safe, often increasing the measure to 50.

"Having noted that, the screening process is critically important," Covert says. "Managing patients beyond our capability is not in the best interest of patients, and it would drive up our postsurgery hospital admission rates. Clearly, that is what we are trying to avoid."

Any migration of complicated procedures to an outpatient setting would ultimately be beneficial for patients, ASCs, and hospitals, Priest says.

 

"One of two things will happen," he says. "First, it will shift so we'll have more medical and nonsurgical patients [in the hospital] because across the country we're seeing the growth of admissions to the hospitals for patients with chronic illnesses. So there may be a shift to those complex medical patients being admitted and filling up beds of those surgical patients with lower acuity."

The second option is that medicine will evolve and develop a new procedure that will require hospitalization, Priest says.

"American medicine is good at solving patient problems," he says. "We'll figure out how to operate because people have a need. There will be a new complex procedure on the brain or a cancer procedure that will take up that backfill in the hospital. It will be more complex and will be something we didn't think we could do today."

Changing marketplace
Covert says that the new rule could potentially make hospitals' outcomes look better but make ASCs' outcomes look worse, but "that is why we have tight preoperative screening processes in place to uphold managing the right patient in the right venue."

The new rule will ultimately help ASCs and patients by separating the good from the "not-so-good," Priest says.

"If you have a surgery, your goal is to get home," Priest says. "Our burden is to try to minimize the time [patients] spend in the hospital, if we can do it safely. This rule will also allow us to create an infrastructure in those environments that will allow us to take care of sicker patients."

Of course, ASCs could opt to not report their quality metrics and take the 2% payment reduction, but it does not seem likely.

"Margins are very tight in our industry, so I find it hard to believe that an organization would forgo that payment," Covert says. "Having noted that, there are many small, standalone organizations that are going to find themselves conducting business in a new way and holding themselves to a higher standard. It will be a steep learning curve for the smaller players."

In addition to a payment cut, ASCs that choose not to report will risk being vilified by competing organizations for their lack of transparency. While reporting organizations risk looking inferior to the surgery center down the road with better quality scores, it fosters an environment of positive competition that will benefit patients.

"It's pretty hard to not be willing to tell people whether you have wrong-site surgeries because I'm walking into your ASC with my iPad and looking up data on everybody—including you," Priest says. "It changes the game."

All in all, the new reporting measures will help surgical centers create systems and processes that measure other quality metrics.

"It will improve patient care and attract patients to Bon Secours and attract physicians and nurses that want to improve patient care," Priest says. "The measures are a good place to start. It's something the public deserves. We don't need to be shrouded in secrecy, and the more transparent we are, the more we're able to solve our challenges, so I'm pretty upbeat about it."


This article appears in the June 2012 issue of HealthLeaders magazine.

Reprint HLR0612-10

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Marianne Aiello is a contributing writer at HealthLeaders Media.

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