Same-Day Surgery asked for more information about compliance and regulations in 2018 in a Q&A with Gina Throneberry, RN, MBA, CASC, CNOR, director of education and clinical affairs at the Ambulatory Surgery Center Association (ASCA) in Alexandria, VA. Throneberry also serves as the executive director of the Board of Ambulatory Surgery Certification (BASC).
Throneberry offered the following answers to written questions about what kind of changes ASCs might encounter this year.
SDS: Which regulatory compliance issues should every ASC focus on in 2018? What are some areas of compliance that ASCs find most problematic?
Throneberry: ASCs must make certain they are compliant with all the regulatory requirements that apply to them all the time, but compliance is especially challenging when new regulations and other changes occur. In November 2017, for example, Medicare began enforcing new emergency preparedness requirements. ASCs must review these requirements along with their facility’s policies to make sure they comply.
A lot has changed in sterilization and infection prevention recently, as well. ASCs should routinely review Medicare’s ASC Infection Control Surveyor Worksheet and make sure they are doing all they can when it comes to following best practices in sterilization, instrument reprocessing, hand hygiene, safe injection practices, and everything else related to preventing infections in their ASC.
In October 2018, licensed healthcare professionals working in ASCs will be able to obtain a certification that will allow them to demonstrate their understanding of the skills and knowledge required to fill the role of an infection preventionist in an ASC. The new certification program, Certified Ambulatory Infection Preventionist (CAIP), will be offered by the BASC and will indicate an individual’s commitment to ensuring they are current on proper infection practices in the ASC setting. For more information, go to: www.aboutcaip.org.
Another area that ASCs must study closely this year is their compliance with the new Life Safety Code requirements Medicare put in place recently. ASCA’s annual meeting in Boston, April 11-14, will include an intensive, two-part pre-meeting workshop on this issue, and the main program will include multiple sessions on infection prevention and emergency management.
SDS: What are some strategies for ASCs to avoid future reductions in their Medicare reimbursements?
Throneberry: For Medicare’s ASC quality reporting program, facilities must remember that the data for ASC-9, ASC-10, ASC-13, and ASC-14 are reported via QualityNet. To report and access the data for these measures, ASCs must employ an active security administrator. ASC management experts highly recommend employing two active security administrators in case of staff turnover at a facility. To keep their ASC’s account active, the active security administrator must remember to log in to the secure portal every 60 days. For ASC-8, ASCs report this data in the CDC’s National Healthcare Safety Network (NHSN). Of the 221 facilities that are subject to a 2% reduction in their 2018 payments, 95 of those failed to report their data in NHSN. It is important for the user of the Secure Access Management Services account to log in within a 12-month period, or their account will be deactivated.
SDS: What are some of the future changes that you anticipate might occur?
Throneberry: As Medicare’s ASC quality reporting program continues to evolve, we can expect that some measures will be added, and others will be taken away. Two measures that are currently under consideration for addition are Ambulatory Breast Procedure Surgical Site Infection Outcome Measure and Facility-Level Quality Measures of Unplanned Hospital Visits within 7 Days after Selected Ambulatory Surgical Center Procedures (general surgery). Beginning in 2018, ASCs will no longer have to report data on three measures: ASC-5, ASC-6, and ASC-7.