Ambulatory Surgery Centers Seek Relevance While Lagging in Transparency

Oregon’s outpatient surgery centers are behind other healthcare organizations in reporting medical errors and infections

January 27, 2012 -- Oregon ambulatory surgery centers want to be an integral part of any newly formed Coordinated Care Organization. But some question just how transparent the 86 freestanding outpatient centers in the state are when it comes to reporting quality.

Participation by ASCs in the Oregon Patient Safety Commission has been slow, now with 58 percent of the facilities reporting severe medical errors. By comparison, all of Oregon’s hospitals are currently taking part in the hospital error-reporting program. And more than 75 percent of nursing homes have agreed to participate.

“It’s fair that we’ve had a little bit more of a challenge in reaching those smaller, more rural facilities,” said Bethany Higgins, the commission’s executive director.

But Higgins said the commission is making progress. Oregon ASCs now use a “safe surgical checklist,” pioneered by the commission. They also offer training courses on infection control, which many ASCs have taken part in, Higgins said.

“The training around infection protection seems to have caught a lot of interest,” Higgins said. “I’m really encouraged by that.”

But, when it comes to reporting rates of healthcare acquired infections, ASCs have largely avoided slower to publicly report as hospitals have been doing for the past several years. However, those ASCs that do partipicate have a much higher rate of reporting than, say, nursing homes. Only 8 percent of pariticpating nursing homes reported errors to the commission compared to 61 percent of participating ASCs.

While outpatient surgery centers typically involve elective procedures by relatively healthy patients, significant infections can occur especially with the use of endoscopes for colonoscopies. Based on a survey of ASCs last year, gastrointestinal endoscopy accounted for 25 percent of the procedures done by outpatient centers in Oregon.

Naomi Price, a consumer representative on the Patient Safety Commission, who looks closely at the infection rates, believes the state has been derelict in not requiring ASCs to report that information to the Legislature. The Health Care Acquired Infection Rate Committee has been in existence for the past four years.

“The Legislature, in devising the infection reporting statute, required the ASCs to start reporting the same way as hospitals,” Price said. “However, in rule making the state sidestepped the wishes of the Legislature and has stepped away from that requirement and just made baby steps.”

Oregon ASCs sincerely want to report infections, said Kecia Rardin, president of the Oregon ASC Association. It just needs to be meaningful, she said. For more than a year, committee members have been debating how best to report those rates. 

“They have not been asked (to report infections by the committee) because the majority of ASCs are not performing procedures that are similar to the procedures that infections are being reported on in the hospital setting,” Rardin said. “It’s been a challenge to decide what procedures to have them report on.”
For instance, in order to determine an infection, an ASC would need to do post-discharge monitoring, something not required of hospitals, which only report infections when patients are still in the hospital. This is a sticking point that the Infection Rate Committee is trying to reconcile, said Dee Dee Vallier, a consumer representative. 
Also the vast majority of infections acquired at hospitals, some 80 percent, show up after the patient returns home, according to the CDC.
“Using the CDC statistics, we’re only getting 20 percent of the surgical site infection rates at hospitals,” Vallier said. “They’re supposed to be doing follow-up surveillance but the hospitals aren’t. The hospitals aren’t doing it so it really wouldn’t be a fair playing field if we asked ASCs to do it.”
Because ASCs specialize in so many different types of procedures it makes it increasingly difficult to report meaningful quality data, but the association is committed, Rardin said. Infection rates are low at ASCs, which should be something to highlight, she said.
As for the patient safety commission, Rardin said almost all of the facilities that belong to the Oregon ASC Association are participating and that reporting rates among them were robust.
“There’s a benefit of not taking healthy patients into an environment where you have a lot of sick people,” Rardin said. “That doesn’t mean there isn’t a lot of things surgery centers should be reporting. Our responsibility is to find out what we can report that’s going to do the most good for the most people and be a benefit.”
Value and transparency become increasingly important as ASCs and other specialized areas of medicine are eager to participate in the Coordinated Care Organizations that will manage the state’s Medicaid program.
“Surgery centers have already shown our ability to perform high quality care at a fraction of the price,” Rardin said. “We’re saving Medicare billions of dollars per year at the national level. We’re a prefect model for an accountable care organization.”
Price urged ASCs to become more transparent when it comes to quality reporting if they want a greater share of the healthcare dollar. 
“If ASCs want to be part of CCOs, that could be a great thing to integrate care and have it happen in the most appropriate setting,” Price said. “At the same time, the accountability aspect has to be integrated into this and right now I don’t see that’s happened yet.”
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Just read the Lund Report on the lack of ASC "transparency" entitled, "Ambulatory Surgery Centers Seek Relevance While Lagging in Transparency". The title and conclusions are misleading based on the information provided in the article. So… ASC are "lagging in transparency" because they are not submitting reports to the Oregon Patient Safety Commission on criteria that the Health Care Acquired Infection Rate Committee has not yet formulated. ACS are thus guilty of not providing data about post-op acquired infections they have not been asked to provide to the Oregon Patient Safety Commission. Amazing thought process! However, even though the CDC has called for hospitals to do post-discharge monitoring for infections, hospitals in Oregon are not doing post-discharge infection monitoring. The result, according to the CDC, is that approximately 80% of infections acquired in hospitals are not being identified. So why is the Oregon Patient Safety Commission not concerned about this large number of hospital acquired infections that are not being identified. Why has the Health Care Acquired Infection Rate Committee not required hospitals to do post-discharge monitoring as recommended by the CDC? I suspect the reason is because hospitals have resisted doing this monitoring because they know their infection rates would go up significantly and hospitals don't want the public to know this information - so are hospitals "lagging in transparency"? I didn't see this "lack of transparency" articulated in your article. Many ASCs already do post-discharge monitoring for infections in patients who have surgery in their facilities. The fact that this information is not being reported is not because it is not available or because ASCs are resisting proving this information, but because the Health Care Acquired Infection Rate Committee has not yet figured out what and how they want this information reported. This is not because ASCs are "lagging in transparency", but because the state is lagging in implementing a acquired infection monitoring system that is applied equally to all facilities providing health care - hospitals, ASCs, and nursing homes. When that system is put in place, ASCs will provide the information available. The results will show what the ASC industry already knows - the risk of acquired infections in an ASC is very low compared to hospitals. Acquired infections are primarily a hospital problem, not an ASC problem, but ASCs are ready and willing to provide the information about acquired infections as soon as the state figures how what information they want. In the meantime Naomi Price, consumer representative on the Patient Safety Commission, needs to focus on hospitals where acquired infections are a problem and stop making inflammatory statements about ASCs. The transparency problem is not with ASCs, but with hospitals, where approximately 80% of acquired infections are not reported, according to the CDC. Is this a real problem? Yes! Why do you not inform the public of this real problem? ASCs provide high quality care at a fraction of the cost of the same care provided in a hospital. And the risk of an acquired infection in an ASC is a fraction of the risk a patient faces in a hospital. The public needs to know this information and ASCs will demonstrate this with real data as soon as the system is set up to allow for meaningful reporting of this very important data. There is no "lagging in transparency" on the part of ASCs, but there is a huge lag in transparency on the part of hospitals. Your article is a disservice to the public because it provides misinformation about ASCs and fails to point out the real problem of under reported acquired infection rates in hospitals because hospitals are not doing post-discharge monitoring as recommended by the CDC. I notice that your Mission is to "shine a light on the Oregon healthcare industry to help create a more accountable and transparent system". The problem of post-op acquired infections is primarily a hospital problem, not an ASC problem, so shine your light where there is a real problem and provide the public real information. You might try putting some new batteries in your flashlight, darrell genstler, md

What a strange article (blog? opinion disguised as news? ... I am not sure how to characterize this piece). You seem to be making the suggestion (particularly with the title) through the entire article that ASCs are hiding something intentionally. The fact is that there is no reporting requirement or easy way to measure these outcomes for ASCs and providing an apples to oranges comparison with hospitals is extremely difficult (hospitals do more complex surgeries in higher risk patients). To use that to cast aspersions is simply a leap that defies logic. You article suggests that because we have incomplete data for hospitals and even less complete data for ASCs, that somehow the ASC's must have inferior quality? Reaching that conclusion "because we have no data" is obviously just opinion. Your discussion of the difficulty in measuring 30 day outcomes is fine. The fact that huge hospitals who do have a mandatory reporting requirement and a lot of staff, time and money dedicated to gathering this data, but still can't find a way to complete the 30 outcome, tells me that this is a quality measure made up without regard to reality. I very much doubt you are ever going to get patient to come back to the hospital (or ASC) 30 days later for a "government oversight checkup" and the ones that did wouldn't ever be the good outcomes, so would be a skewed sample. Less complex day procedures often do not require any kind of patient follow up whatsoever (example, normal screening colonoscopy ... why would you waste the patient's time and healthcare dollars having the patient come back for a follow up visit just to repeat to them that their procedure was normal?). "While outpatient surgery centers typically involve elective procedures by relatively healthy patients, significant infections can occur especially with the use of endoscopes for colonoscopies. Based on a survey of ASCs last year, gastrointestinal endoscopy accounted for 25 percent of the procedures done by outpatient centers in Oregon." "Especially with the use of endoscopes for colonoscopys"? Where did this come from? Again, the suggestion after the title and initial tone of this article is that colonoscopy is a high risk procedure here and that somehow it is higher risk in an ASC? This needs a source citation because I suspect this is just some urban myth or personal opinion you are repeating. You can get an infection and complication from any medical procedure no matter where it is performed. To single out colonoscopy is an odd choice given that it may be one of the absolute safest procedures performed in ASCs. The infection rate attributable to colonoscopy is about one in 1 to 2 million (your chance of being struck by lightning living in the US is two to four times as high). Unlike colonosocpy and endoscopy, any procedure that requires general anesthesia and/or involves a skin incision (no matter where it is performed, hospital, ASC, office procedure room) is going to have a higher risk than that but it doesn't mean it isn't a reasonable patient decision to have a procedure done. Are there reported cases of misprocessed scopes and possible infectious exposures? Yes, there are but interestingly those are all from hospitals, extremely rare even there and if you did a little research you would find all endoscopic ASCs in Oregon quite serious about correct sterilization and endoscope reprocessing. I think the disconnect here by laypeople and administrators with no practical medical background is that too many think all medical procedures, be it a moderately sedated 10 minute upper endoscopy or an 18 hour heart/lung transplant and everything in between, somehow carry the same risks and should all be put on a level playing field for outcomes. Absolutely we need to do everything in our power to make sure both patients are receiving quality care and everything is being done to avoid preventable complications, but a one size fits all oversight model obviously is massive overkill and a waste of money and resources for quick extremely low risk procedures (the ones often done in ASCs). A number of the proposed "safe surgery" measures that are necessary for complex cases in a hospital simply don't apply to those done in ASCs.