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Kathy Wilson – Accurately Tracking & Reporting on the "Wrong Site" Measure
84 Plays1 year ago
Running a surgery center is extremely challenging, and one element that adds to the challenge is collecting, aggregating, and reporting on quality measures. While there are many measures to stay on top of, Kathy Wilson, the Executive Director at the ASC Quality Collaboration, is on today to talk about the measure “Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant.” A few weeks ago, we sourced questions from all of you for Kathy to answer, so we covered topics such as best practices for collecting the data, how to make sure you’re not over-reporting or under-reporting, the importance of benchmarking, and everything in between.
After our conversation with Kathy, we’ll switch to our Data & Insights segment. Today, we’ll cover OR block time, and take a look at the amount of blocked OR time that remains unused, and how you can overcome this challenge.
Resources Mentioned:
Visit the ASCQC’s website for free benchmarking and toolkits: https://www.ascquality.org/home
Download HST’s State of the Industry Report to get your hands on even more data: https://www.hstpathways.com/resources/surgery-center-industry-report
Brought to you by HST Pathways.
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Transcript
Introduction to Podcast Format
00:00:01
Speaker
Welcome to This Week in Surgery Centers. If you're in the ASC industry, then you're in the right place. Every week, we'll start the episode off by sharing an interesting conversation we had with our featured guests, and then we'll close the episode by recapping the latest news impacting surgery centers. We're excited to share with you what we have, so let's get started and see what the industry's been up to.
Challenges in Surgery Centers
00:00:27
Speaker
Hi, everyone. Here's what you can expect on today's episode. As all of you know, running a surgery center is extremely challenging, and one element that adds to the challenge is collecting, aggregating, and reporting on quality measures.
Listener Q&A with Kathy Wilson
00:00:42
Speaker
While there are many measures to stay on top of, Kathy Wilson, the executive director at the ASC Quality Collaboration, is on today to talk about the specific measure, wrong side, wrong side, wrong patient, wrong procedure, wrong implant.
00:00:57
Speaker
A few weeks ago, we actually sourced questions from all of you for Kathy to answer. So we covered topics such as best practices for collecting the data, how to make sure you're not over-reporting or under-reporting, the importance of benchmarking, and everything in between.
00:01:14
Speaker
And after my conversation with Kathy, we'll switch to our data and insight segments. Today, we'll cover OR block time and take a look at the amount of blocked OR time that remains unused and how you can overcome this challenge. Hope everyone enjoys the episode and here's what's going on this week in Surgery Centers.
Kathy Wilson's Experience and Roles
00:01:38
Speaker
Hi, Kathy. Welcome to the podcast. Hi, Erica.
00:01:42
Speaker
Can you please share a little bit about yourself and your healthcare experience? Sure. Yeah. I am right now the ASC Quality Collaboration Executive Director. I've been doing that since January of 2021. Before that, I was with two of the ASC management companies in the quality and risk management area. And prior to that had been a surgery center administrator for 15 years.
00:02:08
Speaker
I've got a comes in nursing and I have a master's in hospital administration. Nice. Very impressive.
Significance of Wrong Site Measures
00:02:15
Speaker
I am really excited to have you on today because as I understand it, and we're just going to refer to it as the wrong site measure to keep it simple, but as I understand it, it's a measure that ASCs can potentially struggle with when it comes to understanding the intent of the measure and how to report data so that it's both accurate and consistent.
00:02:37
Speaker
And we actually source questions from our listeners via LinkedIn and through Instagram and through email. So we have a lot to cover today. So let's just get right into it. Can you please explain the quality measure and why it's important? Yeah. Well, this quality measure, which is wrong site surgery, is really critical to ensuring patient safety in our ASCs.
00:03:05
Speaker
So there are a lot of, there are protocols in place. Example is the universal protocol from the Joint Commission to prevent events happening.
00:03:15
Speaker
to a patient that are not what are intended. So we have a patient that consents to a procedure and we have an intended procedure to be performed, but if something goes off track with that, it can result in the patient obviously having the wrong site, side, implant, et cetera. So we want to make sure that this is tracked so that we're aware of when these happen so that we can address them.
00:03:43
Speaker
These events we call the measure wrong site, but as you said, it includes wrong side, wrong patient, wrong procedure, wrong implant, wrong blocks.
00:03:56
Speaker
and wrong level of pain procedures. Those are just some examples of the things that are included there. So these safety protocols have to be top of mind for all the staff and all the verification processes need to just be baked in from the time the patient registers all the way through their care experience.
00:04:17
Speaker
So the harm that can result from these is extreme. I think we all remember there was a case in Tampa at a hospital where a wrong limb was amputated. That's on one end of the spectrum. But a patient may have to have a lens corrected in the OR if the wrong one is put in. So it's a big variation in the amount of harm that can happen to a patient.
00:04:43
Speaker
But if it happens one time, it's too many. Our patients come in expecting things to go smoothly. And if they don't, we need to know about it quickly. We need to address it. And we need to learn from it. So this is a really important measure. And these are preventable.
History and Status of Wrong Site Measures
00:05:01
Speaker
Sure.
00:05:02
Speaker
And I do understand that it was kind of put on pause and then recently resurrected. Can you just share the history of the measure and the latest as of today? Yeah, sure. Yeah, this measure, which is ASC, along with patient burns, patient falls,
00:05:20
Speaker
and all-cause hospital transfer admissions were four measures that were some of the original ASC measures that were developed by the ASC quality collaboration. And then they were adopted by CMS for use in the ASC quality reporting program.
00:05:37
Speaker
So when we first started reporting these, they were reported through quality data codes that were put on Medicare claims. So a code was actually attached to the claim and that's how Medicare knew that an event had occurred. So when they compiled all that data and they looked at the results were good. There was good performance.
00:05:57
Speaker
So CMS proposed that they be taken out of the Quality Reporting Program because, as CMS refers to it, they were topped out. The performance was so high, so good.
00:06:10
Speaker
However, they got input from us, from the ASC community that these are really important measures to measure patient safety. And just because they were typed out doesn't mean that we should stop tracking them. So they reinstated these measures into the ASC quality reporting program in 2023.
00:06:31
Speaker
The difference now, though, is we don't use quality data codes anymore. We report these through the HQR system, Hospital Quality Reporting System, which is the method that's used for many of these measures on being reported to CMS. And now it includes all patients, not just Medicare patients. So we're back on track with it.
00:06:54
Speaker
Yeah, that's interesting. I feel like last couple of years I've been paying more attention to like the final payment rules and things like that. It's not common that someone on the ASC side is actually wanting to report on all the nuances. So that's actually really interesting and very telling that it was the community that was like, we really actually should be reporting. Yeah, we submitted comments about that. And that's a really important point, Erika, is
00:07:19
Speaker
We all need to stay very engaged in commenting when we can and giving CMS feedback when they ask for it.
Best Practices for Data Collection
00:07:27
Speaker
Definitely. So one question that we got in a bunch of different ways was just obviously best practices for collecting this data and the simplest way to collect the data. We saw that word come up a lot. So what are your tips and advice for collecting it? What would you suggest?
00:07:48
Speaker
It really depends on the center. There's going to be a wide variety of processes in place for this. But at the most basic level, everybody needs a policy and procedure related to adverse event reporting. And all staff need to be really familiar with it. They need to know the timeframe for reporting, what's required.
00:08:09
Speaker
and have a simple form that can capture that information as close to the time of the procedure as possible. That might be electronic, but it can very well just be on paper, but everybody needs to understand the use of those forms, and the forms need to capture all the critical elements.
00:08:27
Speaker
So really important that staff know that and know when to report it and to whom to submit that report. And then typically that will be compiled into some risk management system. That could be a very sophisticated designated risk management system, or it could just be that someone's responsible for tracking it on a spreadsheet.
00:08:50
Speaker
but so important to have that data to be able to track it and see how you're doing over time. So it can vary widely, but it's really important that everybody knows what the process is, whether that be manual or electronic or part of a whole system that the ASC may be involved with.
00:09:11
Speaker
Sure. Just thinking through some of those variances, would case volume come into play? If you're a smaller facility, maybe managing it on a spreadsheet is more realistic, specialties, budget, all of those things. Absolutely. Budget, size, whether you're affiliated with a hospital system that has an electronic system in place. Smaller centers may just be tracking it manually, and that's fine. That's absolutely fine.
00:09:41
Speaker
Yeah, sure.
00:09:43
Speaker
Okay. Let's switch gears a little and talk about CMS. So it seems that obviously CMS has a very specific definition of what they're looking for and what this measure is intended for. But if ASCs don't fully understand those CMS parameters, they might be under reporting or over reporting. So what discrepancies have you seen there between CMS and the ASCs understanding?
Understanding CMS Definitions
00:10:05
Speaker
Yeah, it's a really interesting question. And we've just been looking at this. CMS has a definition.
00:10:12
Speaker
which is a surgical or other invasive procedure that's considered to be performed on the wrong body part if it's not consistent with the correctly documented
00:10:23
Speaker
informed consent for that patient. So it includes not only surgery on the right body part, but also wrong location on the body, left versus right, or level. So that's a definition that you see that's tied with CMS. The actual measure specifications are not very specific. So they actually state all admissions experiencing a wrong site, a wrong side,
00:10:50
Speaker
wrong patient, wrong procedure, or wrong implant. But there are a lot of nuances as we analyze these events, and they may not fall cleanly into those categories. So it's important that we know what really should be considered as part of, for example, a wrong implant. So that could be an expired implant. It could be the wrong lens is placed, the wrong strength lens.
00:11:19
Speaker
There are a lot of nuances to these that have to be sorted out when an event like this occurs. So some centers may say, for example, I've heard some centers say that it's not reported as a wrong if the patient is still in the OR when it's caught. Well, that's not necessarily true. A patient may have not come out of the OR and require a second procedure, and we would consider that a wrong.
00:11:47
Speaker
So there are nuances to it that have to be discussed and you really have to land on what you feel is the best reporting category for that to go into. But yeah, we don't want people over-reporting, but we also don't want under-reporting of it because we want to make sure that all of these are addressed.
00:12:09
Speaker
Sure. And that's actually a perfect segue into another question that we've received was what measures can you implement to educate your staff on the measure as a whole and those nuances?
Educating Staff on Reporting Measures
00:12:20
Speaker
Really important that staff understand the quality reporting program and what all measures are being reported to CMS on behalf of the center because that's publicly reported.
00:12:32
Speaker
And so it's important that the staff, first of all, knows what CMS measures are. But more importantly, I think it's really important to share the stories of these events with staff. When you have staff meetings or department meetings, depending on the size of the facility, to share these stories and people may not be aware of what has happened in their own facility.
00:12:56
Speaker
So, it's really important to, at staff meetings, take the opportunity to tell the stories of these events. And if you can, to talk about the impact on the patient. Because that's what's the most important thing, obviously, in correcting the errors. So, staff may listen to those stories and think, boy, that could have been me.
00:13:19
Speaker
or that's something that I do every day, I need to pay closer attention. So, important that they hear these. The other thing is, I think that's really effective in educating staff about these measures is to post them. And you can, if you have an area in the center that's not, obviously not out in the waiting room,
00:13:40
Speaker
someplace that just staff sees, staff and physicians see. We used to keep a big white marker board with all of these measures on it and track the performance from month to month.
00:13:51
Speaker
People need to know how your center is doing on these measures. And it also prompts conversations about, gosh, I didn't know we had that happen here. And so everybody can really relate to if it's something that they're working on every day and it could be them. They want to make every, take every step to prevent it from happening. It has, it takes its toll, not just on patients, but on staff too.
00:14:18
Speaker
when these adverse events occur. We want to prevent them for a lot of reasons. Yeah, I would imagine so. I think that's a good approach. The education about for pragmatic reasons, here's why you need to understand this, here's what CMS is expecting, but then also that emotional tie-in of here's the reality. Absolutely. Yes, maybe we had to, let's say for the year,
00:14:41
Speaker
And that's an incredibly small number compared to our case volume. But let's think about those two patients now that are, their lives are impacted, probably will be scared to have surgery again, whatever it might be. And there's a reputational component to it. Yeah. If that happens to a patient and they talk about it. And so, yeah, they're just, they're far reaching ramifications when these occur.
00:15:06
Speaker
Yep, definitely. What are some common challenges that you think ASCs are facing right now in trying to collect accurate data?
Challenges in Data Accuracy
00:15:17
Speaker
Yeah, I think it's just normal that there's going to be sometimes a hesitancy to report.
00:15:23
Speaker
And for a lot of reasons, embarrassment, you don't want to make it look like you did something bad or that the physician did something bad. But when a facility has a culture of transparency, that's not an issue because you want to bring those forward. So that doesn't happen overnight, but building a culture of openness and transparency is really important.
00:15:49
Speaker
The other thing is sometimes it just plain creates more work. So you want the reporting system to be as simple as possible with getting all the information you need. Sometimes you have to report them to the state.
00:16:05
Speaker
So there are a lot of places that potentially these have to be reported, but so that's always going to be a challenge. In some states like in Florida, physicians can get fined for a wrong site surgery. So you have to know what your state regulations say about the reporting and what happens to staff that are involved in these. So it's natural that there's going to be a hesitancy.
00:16:32
Speaker
But if the center creates an environment in which there's open discussion of errors that are made and people are involved then in the improvements that are needed, people are going to be more apt to just feel free to report and want to report so that they make sure that the improvements are started and kept in place. Sure. Yeah. And also I would imagine being able to track trends over time.
00:17:02
Speaker
It is incredibly helpful in painting that story of improvement of like, okay, in 2022, we had X amount, 2023. And I think telling that story. I think another challenge, Erica, that people are having now really is continued is with staff turnover and more use of temporary staff. There may be an unfamiliarity with what the center's processes are for reporting.
00:17:31
Speaker
And processes in general, not just for reporting, but for the verification steps and the timeout and what is in place at that center. So the orientation of new staff or temporary staff is so critical in this. And that just continues to be a challenge everywhere now with staffing. Yeah, for sure. Throughout this whole conversation, I can't help but always think about the importance of benchmarking as well.
Importance of Benchmarking
00:18:00
Speaker
in comparison to your peers and going back to that idea of transparency. And it's like, yes, we do have to report these numbers, but at least you can give you peace of mind if you're looking at other benchmarking data of like, we are not the only surgery center experiencing these numbers.
00:18:15
Speaker
And one, one thing that we always try to really hammer home with clients in any conversations we're having is the importance of data and having these data driven conversations and all of your operations should be focused around data. And I think when we were making our state of the industry report last year, I turned to the ASE quality collaboration to look at your benchmarking data as well, because you offer a tremendous amount for free.
00:18:42
Speaker
two surgery centers to help let them know where they compare to their peers. So I would love to just give you the floor for a minute and just tell us the data collaboration collects and all of that. Yes.
00:18:55
Speaker
Yeah. When we first developed these measures back before the CMS reporting started in 2012, we had all this data and we realized that there were no benchmarks out there. So the management companies that were involved in the ASC quality collaboration at the time agreed that they would submit this data. Obviously it's blinded, so you can't tell which center it's coming from or which company it's coming from.
00:19:23
Speaker
but submitted on a quarterly basis. And we started posting it publicly. And because there just wasn't a source for it, as you said, anywhere else. So that data comes from about 2000 surgery centers. And it's really a big commitment on these reporting entities on these management companies part to submit and contribute to this. We so appreciate it.
00:19:51
Speaker
But so anyone can go out to the ASC quality collaboration website, which is ASCquality.org and pull that report that's posted every quarter.
ASC Quality Collaboration Data
00:20:02
Speaker
And it has rates per thousand procedures for most of the measures. Some of them are percentage like normothermia is a percentage, but you can then take your rate and compare that
00:20:16
Speaker
to nationally what we're seeing with our data. And it just gives you a place of comparison, which you don't have otherwise. So are we doing poorly? Are we doing more normally compared to other surgery centers? So that's true with all of those measures. And we welcome people to use it and incorporate it into their quality improvement plans for the centers.
00:20:41
Speaker
Yeah. Yeah. We will definitely include a link to the website in the show notes too. And I think having free access to benchmarking data like that, I'm just thinking about these admins and CEOs having to go to their quarterly board meetings too and present on the wrong site data. And if anyone starts pushing back, at least you have the benchmarking data to turn back to and say, hey, yes, we did experience X, but the average is actually Y. So while it's not ideal, we're not out of the norm.
00:21:11
Speaker
So, yeah, I think that's an amazing resource that you all offer. Yeah. And it's important to us that it's available free to everybody really for all surgery centers across the country to benefit from it. Yeah. Love it. All right, Kathy. Last question. We do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers?
Improving Operations with Verification Steps
00:21:38
Speaker
I would say go back to the basics. Sometimes that's what we need to do. And as we've been discussing, I think you really have to just take a step back with wrong site surgery prevention and make sure all those verification steps, the timeouts are in place, monitor it.
00:21:57
Speaker
look to see that it's being done and that it's being recorded as such. So sometimes we can get so busy and so involved in intricacies of quality programs, but we have to go back to the basics and think about the impact on patients.
00:22:18
Speaker
So this is just such a key measure in maintaining patient safety. And everyone in the facility needs to understand how critical it is that if they're assigned a process as part of this, that it's carried out consistently for every single patient. Perfect. Thank you. And thank you so much for coming on and answering all of our listeners' questions. We appreciate it. You're so welcome.
00:22:48
Speaker
Welcome to Data and Insights, where we turn data into dialogue and numbers into narratives.
Impact of Unused OR Block Times
00:22:55
Speaker
Now, if you're an avid listener of the show, you'll know that this is our third time doing this segment and the third intro that I am testing out. The other two episodes were on December 12th and January 16th. If you did want to give them a listen because they had different opening lines for this segment. I do think I'm leaning towards a variation of today's intro though, but if you feel differently, please leave a comment on this LinkedIn post to let me know.
00:23:20
Speaker
Anyway, HSC Pathways released a state of the industry report last year, highlighting best practices, key process steps, and KPIs for every step of the patient journey and for nearly every recurring administrative duty. Most importantly though, using our own data set from our clients, we were able to extract data points so that anyone in the industry could compare themselves to their peers.
00:23:45
Speaker
Two disclaimers, we only pulled data from clients who gave us permission and we omitted any extreme outliers. So after analyzing data from over 450 ASCs across the country, we were able to determine that on average 42.2% of blocked OR time ends up going unused.
00:24:07
Speaker
Our data analysts derived this metric by first identifying the scheduled time blocks allocated to specific physicians. Then they determined the percentage of unused time within these blocks by dividing the total amount of unscheduled time by the entire duration of the block. And it's important to note that this metric only takes into account scheduled blocks and does not look at overall unused OR time across the surgery center as a whole.
00:24:34
Speaker
So why does this data point matter? The financial performance of a surgery center is directly impacted by how well it utilizes its OR and its block time. Unused or wasted block time represents missed opportunities for revenue generation. So for example, perhaps there was another physician who could have scheduled surgery at that time, but they were unable to.
00:24:58
Speaker
that directly equates to revenue loss. So by analyzing block time utilization trends, you can make informed decisions such as adjusting scheduling practices or introducing new specialties, or perhaps there are some physicians that have higher unscheduled block times than others. And while it might be a tough conversation to have, you can use this data point and another data point such as revenue per OR per minute to help all stakeholders understand the potential
00:25:28
Speaker
opportunity if you did take the time to adjust some of your black time practices.
00:25:33
Speaker
And if you're not seeing the success that you'd like to in this area, perhaps there's too much unused time. Perhaps focus on fostering communication and collaboration amongst your staff members involved in scheduling surgical procedures. And that will just help to make sure that everyone understands the importance of efficient block time utilization and how everyone can work together to achieve your facility's goals. I also would recommend sharing a stat like this in your quarterly board meetings.
00:26:01
Speaker
In conjunction with some of the other revenue cycle metrics that you're showing, this could be a really good stat. And maybe you just need to do your own internal benchmarking as well and see where you can improve. But I bet if you brought a number like this to your board meeting, it would open up a lot of dialogue for discussion and some of your board members might have some really good ideas too.
00:26:22
Speaker
So if you do track this metric at your ASC, I hope this gives you some context. Again, what we found was 42.2% of blocked OR time ends up going unused. So I would love to hear how our number compares to what you're experiencing. As always, you can comment on our YouTube video or on our LinkedIn post sharing the metrics that you're experiencing.
00:26:44
Speaker
And if you're interested in more data points and use cases, you can definitely subscribe to our podcast so that you don't miss any upcoming segments. Or you can always head to HST's website to check out the full State of the Industry report to get your hands on even more data. And I will include that link in the episode notes.
00:27:03
Speaker
And that officially wraps up this week's podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you're listening from. I hope you have a great day and we will see you again next week.