Surgical checklists come to ambulatory centers

Time outs required as of January

The first part of new federal rules related to quality and outcomes for ambulatory surgery centers (ASCs) went live in January, with a requirement to implement a surgical safety checklist. While many ASCs started using checklists years ago, others are just getting on the bandwagon. Others are taking the opportunity to revise the checklists they were using to make them more comprehensive. That's what they did at the Center for Ambulatory Surgery in West Seneca, NY, according to Paula Williams, RN, the center's director of operations. "We had one when I started a year ago," she says. "But we started over because what we had didn't cover everything we thought it should."

Rather than use an existing template, Williams says they opted to take bits and pieces from samples offered by the Association of periOperative Registered Nurses, the World Health Organization, and Accreditation Association of Ambulatory Health Care and created something completely new.

It is a document that Williams is particularly proud of — indeed, she will be presenting it at a national meeting later in the year. Along with some of the typical recommended elements, Williams' checklist includes a requirement for all providers in the operating room to sign that there was a time out. It is one element that providers at the center are still struggling with — not out of any ornery resistance to change, but simply because they aren't used to the requirement. Currently, it's up to the nurses to "be the police and remind physicians and anesthesiologists that they have to sign," she says. "We're still doing that kind of chasing."

The goal of any checklist is to reduce or eliminate harm, but Williams wants a little more — to determine the number and kind of near misses, and hopefully to eliminate them. But she doesn't think that a checklist will do it. "I think what makes this have an impact is that the complexity of it — from registration, to preop nurses to procedure nurses — and that there is a checkpoint at each stage. They have to stop. They have to communicate. That's what it's about — the communication, not the tool."

The notion that a piece of paper can solve a problem is false, she continues. "It's not about the piece of paper or what's on it or auditing what's on it. It's about the ritual of the time out and whether you communicate what needs to be communicated and do it properly."

Indeed, one of the things Williams considered while working on the checklist was the increase in emphasis on handoffs evident in the National Patient Safety Goals. "We made sure to incorporate the need to communicate pertinent information at every handoff." They have also created boards to go into each OR that will have the same information as the checklist with sliders that go from red to green if an element is completed. Again, it's not about the board, but about the reminder to communicate "nurse to nurse to anesthesia to physician," she says.

Other elements of CMS's Ambulatory Surgery Center Quality Reporting Program include:

  • reporting on five measures — patient burn, patient fall, wrong side/site/patient/procedure/implant, hospital admission/transfer, and prophylactic IV antibiotic timing — October 2012 or face a 2% payment penalty applied to 2014 payments;
  • reporting on an additional two measures for 2015 payment determination, including safe surgery checklist use and ASC volume data on selected procedures;
  • reporting on an additional measure — flu vaccination coverage among health care workers — for the 2016 payment determinations.

For guidance for creating a checklist, visit the World Health Organization website:

For more information on this topic contact Paula Williams, RN, Director of Operations, Center for Ambulatory Surgery, West Seneca, NY. Telephone: (716) 677-4400 ext. 313.