With more than half of hospital surgeries performed in an ambulatory setting, some quality improvement professionals are questioning whether there are adequate metrics for measuring quality and patient safety.
Sixty percent of hospital surgeries are ambulatory, according to a report from the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD. More than 17 million hospital visits in the United States in 2014 included at least one ambulatory surgery.
“Just over half of these visits (57.8%) occurred in a hospital-owned AS [ambulatory surgery] setting, and the remaining visits (42.2%) occurred in the hospital inpatient setting,” the AHRQ report says.
“These visits included nearly 22 million total surgeries, over half of which (52.7%) were performed in an outpatient setting. The average number of surgeries performed per visit was slightly higher in the inpatient than in the outpatient setting (1.4 vs. 1.2).” (The report is available online at: https://bit.ly/2XTQqAY.)
Eligible Medicare-certified ambulatory surgery centers (ASCs) in 2019 must report these five Centers for Medicare & Medicaid Services (CMS) measures to avoid Medicare payment reductions in 2020:
- ASC-9 — Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients;
- ASC-11 — Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery;
- ASC-12 — Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy;
- ASC-13 — Normothermia;
- ASC-14 — Unplanned Anterior Vitrectomy.
More Measures in Development
Ambulatory surgery is still developing quality measures, so hospital-based quality improvement leaders will not find as many metrics in this area as they are used to for inpatient care, says David Levine, MD, FACEP, senior vice president for advanced analytics and product management with Vizient, a company that provides healthcare performance improvement assistance.
“For the field of ambulatory surgery, the metrics there are where hospital quality measures were about 15 or 20 years ago,” Levine says. “As the delivery of certain elements of medicine shifts to ambulatory care, the quality measures need to focus more on these ambulatory surgery centers. What is positive is the continual evolution of measures we’re seeing, driven partly by CMS but also by ambulatory surgery society.”
Most of the available measures are process-oriented rather than outcomes-based, Levine notes, and many are voluntary. Those will have more limited utility than measures used in the inpatient arena, he says.
“It’s encouraging to see a nice alignment between CMS measures that would be used for inpatients and those used for outpatient care in the surgery centers, applying those same quality standards to the other setting,” Levine says.
“Ideally, the outcome should be the same regardless of the site where the surgery was performed, so there is good reason to carry those same metrics over to ambulatory surgery.”
Monitor Post-Surgery Admissions
Levine also is encouraged by an improvement in assessing quality in the continuum of care, with more hospitals following ambulatory surgery patients to determine whether they get admitted to the hospital within a short time. That may be a flag for a complication and possibly a concern about quality of care in the ASC, he says.
The industry is moving in the right direction with ambulatory surgery quality metrics, but too much of the measures require manual chart review and submission, says Elizabeth Godsey, vice president for advanced analytics and informatics with Vizient. The claims data that CMS collects from ASCs tends to only focus on Medicare patients and can be outdated by the time CMS compiles it, she says.
CMS appears to be moving toward more mandatory quality measures for ASCs, Levine says. “From the current CMS rules and the direction they’ve signaled, I see growth in that area, and I applaud that growth,” Levine says.
“The challenge is to develop meaningful measures that require a minimal amount of effort to collect and that can be timely, actionable, and appropriately risk-adjusted to the patients so it can be an apples-to-apples comparison.”
Use Hospital Measures for ASCs
Even before those ASC-specific measures are promulgated, hospital quality improvement professionals can apply many inpatient measures to the ASC setting, Levine says.
“Key areas to look at are complications during and after a procedure and appropriate follow-up after a procedure, especially if there is a biopsy,” Levine says.
“You also want to look for patients who bounce back unexpectedly, which potentially could be a signal that there was a quality improvement opportunity. That doesn’t have to be just inpatient admissions because those patients may present at the emergency department with pain or bleeding.”
Godsey notes that the CMS quality reporting program for ASCs includes data that quality improvement leaders can use to assess their own ASCs against the performance of others.
“It would be very helpful and informative for ASCs to leverage that data to see where they compare not only within their health system or surgery center network but also across the country,” Godsey says.
“There are opportunities for benchmarking there that can be useful now, before specific additional measures are introduced.”
ASCs Must Meet Multiple Standards
Jason Kofinas, MD, FACOG, carefully considered these issues when he and his colleagues at Kofinas Fertility Group recently opened the Manhattan Reproductive Surgery Center in New York City.
It is the first standalone reproductive ASC in the state focused solely on endometriosis and uterine fibroids. New York State’s criteria for ASCs are stringent, he says, and the center must also meet CMS specifications. The next step is accreditation through the Accreditation Association for Ambulatory Health Care.
“They go with the quality measures that are dictated by Medicare and Medicaid, which are pretty much the same infection control and life safety code requirements that hospitals must meet,” Kofinas says.
“That means unannounced visits by the accreditation body and of course yearly reporting to the Department of Health on infection rates and transfers to hospitals. These are statistics that we keep and report to the state every year to determine if we are meeting the standards for quality and safety.”
The ASC also conducted drills for three months before opening, running through generator tests, mock codes, and other scenarios to ensure the facility was ready for patients, Kofinas says. Those drills went beyond anything required for accreditation, he adds.
Kofinas cautions that although the number of formal quality measures may be limited for ASCs, there are plenty of mandates from state health departments requiring extensive fire safety measures and other patient safety precautions. It took four years for the ASC to be completed and open for business, he says.
Data-sharing across ASCs is another concern, says Mark LaRow, CEO of Verato, a company based in McLean, VA, that offers cloud-based patient identity matching. The inability to match patients with data across disparate ASCs that are not sharing data or do not have infrastructure to digitize records complicates any effort to address quality standards, he says.
“For example, let’s say a patient has an appendectomy at a surgery center in one city and then travels to another city and has complications. They are likely to visit an ASC that is not sharing data with the first center, which creates challenges for the second ASC that is trying to administer care,” he says. “In addition, the first surgery center would not have a record that the patient had complications if an audit were to take place, and would not be flagged by regulators.”
Another concern facing ASCs is the technical infrastructure that would allow for the digitization and exchange of patient data, LaRow says. There is wide diversity in electronic health record types within ASCs, making it even more difficult to establish a common data exchange framework, which makes the sharing and networking of data nearly impossible.
“In order for ASCs to deliver on quality patient care, an overhaul of technology and legacy systems may need to happen before patient data can be shared,” he says. “This would help ensure that no matter where a patient is getting care, healthcare professionals are able to properly access and match patients with their historical data.”
Multiple Components of Accreditation
Medicare’s quality reporting program is just one of the tools ASCs use to ensure and demonstrate quality, notes Kay Tucker, director of communications for the Ambulatory Surgery Center Association (ASCA) in Alexandria, VA.
There also are Medicare’s Conditions for Coverage, certifications for the physicians and staff who work there, accreditation and licensing for the facilities, and other regulatory requirements, she says.
ASCA helped establish the ASC Quality Collaboration in 2006 to create quality and safety measures for the industry. There are about 1,600 ASCs in the group.
Tucker offers these points to consider regarding ASC quality concerns:
• “While ASC measures 1-4 are not being reported this year, they have only been suspended, not removed, from the program, and we fully expect they will be reinstated shortly, something ASCA supports,” Tucker says. “We have reason to believe that one reason they have been temporarily suspended is to allow CMS to look into an alternate way to collect that data that might even allow ASCs to report on all patients, not just Medicare beneficiaries, through this program. Again, this is something ASCA supports.”
• While ASC-17 and ASC-18 will only affect 2022 payment determinations, CMS is collecting those data now.
• ASC-15, the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, is currently voluntary, and some information is being publicly reported as a result.
ASCA supports implementation of an OAS CAHPS survey and is talking with CMS about ways to format the survey to support a successful program, Tucker says.
• According to CMS, one of the reasons some of the measures ASCs reported in the past were removed is that ASCs “topped out” in their performance on these measures, Tucker says.
In other words, performance was so consistently high that there was little room for improvement, and CMS felt it unnecessary to continue collecting those data, she explains.
• “Although ASC quality reporting came into existence after hospital quality reporting, ASCA had been advocating for years for CMS to institute a quality reporting program for ASCs, and the ASC community helped develop and pilot test measures,” Tucker says.
“Because the ASC quality reporting program was developed more recently, it was able to incorporate more outcomes measures than hospitals had at that time. Hospitals initially depended mainly on process measures.”
- Elizabeth Godsey, Vice President for Advanced Analytics and Informatics, Vizient. Irving, TX. Phone: (866) 600-0618.
- Jason Kofinas, MD, FACOG, Kofinas Fertility Group, New York City. Phone: (212) 807-7000.
- Mark LaRow, CEO, Verato, McLean, VA. Phone: (703) 650-5155.
- David Levine, MD, FACEP, Senior Vice President, Advanced Analytics and Product Management, Vizient, Irving, TX. Phone: (866) 600-0618.
- Kay Tucker, Director of Communications, Ambulatory Surgery Center Association, Alexandria, VA. Phone: (703) 836-8808.