To prevent last-minute surgery schedule changes and cancellations, it’s important for ASCs to receive surgical clearance documentation at least three days before the scheduled procedure. For one ASC, this was not happening often enough.
- The ASC found that last-minute surgical clearance documentation put pressure on anesthesiologists to review patient information quickly, which sometimes resulted in patient cancellations.
- After tackling the issue through a quality improvement project, the ASC reduced its variance report rate from 10.35% to 2.17%.
- After collecting and analyzing data, one of the first steps was to meet with referring providers to discuss the problem and seek solutions.
Before the ASC focused on the problem, there were too many incidences in which surgical clearance documentation arrived late — sometimes as late as an hour before the surgery.
“They should arrive at least three days out,” says Craig Rosfjord, RN, BSN, PhN, quality improvement and safety RN at Mankato Surgery Center in Mankato, MN. Three days is the amount of time necessary for reviewing the documentation before patients arrive for their surgery day.
The late-arriving documentation could result in a patient cancellation. It also puts pressure on the anesthesiologist to quickly review the patient’s information before clearing the patient for surgery, he says.
“Because of findings in the documentation, the anesthesiologist might say, ‘You need another lab test, and that would cancel the patient,’” Rosfjord says.
Mankato Surgery Center tackled this problem, starting several years ago, says Joleen Harrison, RN, BSN, PhN, CASC, administrative director at Mankato Surgery Center.
“In the last year and a half, we’ve made really great strides,” she says.
For example, the surgery center’s baseline variance report rate was 10.35%, meaning slightly more than one in 10 surgical clearance documents arrived late. Now, the variance report rate is 2.17%. The quality improvement resulted in the ASC being named a finalist for the 2016-17 annual Bernard A. Kershner Innovations in Quality Improvement Award by the AAAHC.
The following is how the ASC addressed the problem:
1. Collect data. Rosfjord collected data on how frequently the surgical clearance documentation arrived late.
“I collected incidence reports that people were filling out and, then, from there I went in and verified the electronic medical records they received here,” he says.
With a month’s worth of inpatient data, Rosfjord collected metrics on total procedures, variance reports, and referring clinics and physicians.
“It came down to the health history and physical form,” he notes. “The HHPF was the documentation that was lacking the most, and it was always the latest.”
He found late documentation resulted in a very small percentage of surgical delays, and had not yet caused a cancellation. But the late arriving paperwork resulted in preoperative intake nurses having to spend time making additional calls for the surgical documents to ensure they arrived in the morning of the patient’s procedure.
2. Meet with referring providers. Rosfjord met with leadership at the multispecialty clinics that delivered surgical clearance documents latest.
“I explained what the issue was and our goals for when we wanted the documentation to arrive,” he says. “We wanted the documentation equal to or greater than three days out.”
In introducing the problem, Rosfjord made certain the clinic leaders knew his purpose wasn’t to find fault or point fingers. “This is an issue that we can work together to resolve mutually,” he says.
The clinics and ASC are part of the same large healthcare organization, Harrison notes.
“We’re together in the organization to work collaboratively and help patients as best we can,” she adds.
Multispecialty clinic directors took this information to their managers, staff, and physicians, and began to educate everyone about how to get the documentation in on time.
3. Learn reasons behind delays. For education to work, the ASC needed to figure out why the documentation was late.
“One thing we found in our discussions in multispecialty clinics is that schedulers, in their zest to provide excellent service, would schedule surgery within days of the consult, not realizing there wasn’t enough time for the primary care physician to get the history and physical, labs, X-rays, and maybe a cardiology consult,” Rosfjord says.
Also, some providers didn’t know the documentation had to be returned to the ASC so quickly.
“It wasn’t intentional that they were holding things back,” he adds.
Another issue that slowed the documentation was that it took time for patients to get in to see some specialists, such as a cardiologist for a consult before surgery. When the ASC met with the multispecialty clinic, one cardiologist also attended the educational session and learned how important it was for the ASC to receive the cardiologist’s consultation information quickly, Harrison notes.
“The cardiologist decided to see certain surgical patients at a quicker pace, moving them up to a high priority so the information could come back sooner,” Harrison explains.
4. Assess improvements. The supervisor of scheduling services of the multispecialty clinic attended the educational session and then took the information to her schedulers to find a solution. They decided to check patients’ electronic medical records to see when they were scheduled for a pre-op physical. They would schedule the surgery for a week after that date, giving providers enough time to collect lab and radiology results and submit paperwork to the ASC, Rosfjord notes.
“After the education, we waited a couple of months, and then I did a second study to see what kind of improvements were made,” Rosfjord says.
It worked: The variance report rate dropped from more than 10% to about 2%. The 2% rate has held up since then.
“We are now concentrating on other items, such as patient surgical consents’ accuracy, when they are filled out, incompletely, in the offices and sent to our facility,” Harrison says. “This is making up about 1% of the 2% remaining variances we receive.”
To compare its variance report rate with other ASCs, Rosfjord checked online and found a little information, suggesting that a good goal is to reduce variance report rates to less than 5%. Anecdotal evidence suggests there have been additional benefits to improving documentation timeliness. For example, ASC nurses have more time to review patient histories. They can focus on more important aspects rather than taking time to find the health and physical documentation, Harrison says.
“Nurses now can look for issues that need to be brought to the surgeon’s attention,” Harrison says.
Submitting documentation on time reduces stress on ASC staff, notes Garret Hilgendorf, MBA, department manager for nursing and quality at Mankato Surgery Center.
“[Eliminating] some of those panic moments before surgery has increased their engagement,” Hilgendorf says. “They can go into surgery well prepared without having to scramble at the last moment to get some of that documentation.”
The quality improvement project’s success largely was because of team efforts by all stakeholders, Hilgendorf notes.
“Overall, we have a great team that really works well together to make sure every surgery goes off without a hitch, and this was a huge step in making that even better for patients,” he says. “We’ve eliminated things we need on the day of surgery, so staff can focus on what they need to do with the patient in front of them.”