the monthly publication for or decision makers

August 2009 Vol 25, No 8

The monthly publication for OR decision makers

In this issue

JOINT COMMISSION.Surveyors to shift sterilization focus .............5

SCIP: WHAT’S THE STATUS?SCIP: Getting everyone on board...........................10

New SCIP measures being introduced.............12

SCIP: VTE prevention controversy......................14

OR BUSINESSMANAGEMENT.‘Never events’: Sorting out confusion...................21

MANAGING PEOPLE.Engaging your staff in hard times ...................23

AMBULATORYSURGERY CENTERS.Staying on top of code requirements ..........25

AMBULATORYSURGERY CENTERS.Recouping costs on out-of-network................28

AT A GLANCE ...............32

ASC section on page 25.

Surgical Care Improvement Project:Four years later, what’s the status?

90-day guarantee: Warranties as a tool for improved patient outcomes

SCIP: What’s the status?

Performance improvement

Everything from washers to carscomes with a warranty, so whynot health care? Geisinger

Health System in Danville, Pennsyl-vania, introduced health care war-ranties with an innovative programcalled ProvenCare. Under the 90-day warranty, one cost covers thesurgery and 90 days of follow-uptreatment. Geisinger absorbs anyadditional costs of related complica-tions and readmissions in the first 90days.

The system’s first program, elec-tive coronary artery bypass surgery

(CABG), cut readmissions within30 days by 44%. In-hospital mortal-ity dropped from 1.5% to 0%, andcomplications were all reduced.

Now the system, with 2 hospitalcampuses and 40 community prac-tice sites, has expanded Proven-Care to other high-volume ser-vices, including total hip replace-ment, cataract surgery, and electivepercutaneous coronary interven-tion, as well as low-back pain andperinatal care.

How does Geisinger do it? Al-

Four years ago, the Surgical CareImprovement Project (SCIP)was launched, with the ambi-

tious aim of reducing 3 types of pre-ventable complications by 25% by2010:• surgical site infections• perioperative heart attack• deep vein thrombosis and pul-

monary embolism.SCIP is a national quality partner-

ship led by 10 organizations andagencies (sidebar, p 8).

With the fifth anniversary a yearaway, what impact is SCIP making?Is care improving? What’s next forquality reporting? What role will

SCIP play in an expanded Medicarepay-for-performance program, ifone is approved by Congress?

A way of lifeBy now, SCIP is a way of life.

Hospitals have devoted time and ef-fort to reporting on SCIP and bring-ing their performance in line withSCIP measures and reporting theirdata.

SCIP has teeth. For fiscal 2009, 8SCIP measures are among 30 mea-sures acute care hospitals must re-port to Medicare to receive their fullannual payment update. Hospitals

Continued on page 19

Continued on page 7

3OR Manager Vol 25, No 8August 2009

Slowly, we are seeing momen-tum build for evidence-basedpractice and reducing pre-

ventable errors. We certainly noticedit as we prepared this issue andlearned of recent developments.

In this issue, you can read about 2great examples—the Surgical CareImprovement Project (SCIP) and the90-day warranties for care offeredby Pennsylvania’s Geisinger HealthSystem.

Both programs are working tobring care in line with the scientificliterature and practice guidelines.

As we researched the SCIP sto-ries, we were impressed by thecontribution of Dale Bratzler, DO,MPH, and his team at the Okla-homa Foundation for MedicalQuality, which guides SCIP.

If you monitor the SCIP listserv,you know that Dr Bratzler person-ally answers many questions aboutthe SCIP measures sent in by qualitymanagers and chart abstractors. Thisis the place to go, for example, if youwant to know SCIP’s take on themerits of clindamycin monotherapyfor cardiac surgery or how to re-spond to a physician’s choice of an-tibiotics for transrectal prostate biop-sies.

Critics charge SCIP measuresare “cookbook medicine.” Dr Brat-zler responds, “Hey, if I’m sick,throw the cookbook at me—we callit evidence-based medicine.”

Geisinger’s guaranteeGeisinger is taking a page from

appliance stores and car makerswith its 90-day warranty for coro-nary artery bypass, hip replace-ment, and other conditions. Thewarranty takes evidence-basedmedicine to the next level by back-ing it with a financial guarantee.It’s a model we might see more ofif Congress decides to pushMedicare into more value-basedpurchasing.

There are other examples.

In a 4-year initiative, the MayoClinic in Rochester, Minnesota, hasreached Six Sigma in the preventionof retained foreign bodies, describedin the Joint Commission Journal onQuality and Patient Safety (March2009;35:123-132). Led by a team ofphysician and nursing leaders, theeffort entailed a detailed analysis ofretained objects, a retooling of pre-vention policies, education of 2,500staff and physicians, new “redrules,” and other measures. You’ll beimpressed by their report of what ittakes to dramatically reduce thisstubborn problem.

We also learned of Rhode Is-land’s statewide project to adopt asafe-site protocol for all of its hos-pitals and surgery centers. Leadersworked with the state hospital as-sociation and Joint Commission onthe protocol, which they will spendthe next year implementing.

“We have to have a culturewhere people can say ‘stop,’”William Cioffi, MD, surgeon-in-chief at Rhode Island Hospital, toldthe Providence Journal.

Five wrong-site surgery caseshave been reported in Rhode Islandsince 2007, though the state’s leaderssay they don’t have data to indicatethe problem is more prevalent therethan anywhere else. Still, they arecoming together to end this rare butpreventable event.

After so much effort and frustra-tion, it’s good to pause and say,“We’re getting there.”�

—Pat Patterson

Upcoming

August 2009 Vol 25, No 8OR Manager is a monthly publication forpersonnel in decision-making positions inthe operating room.

Elinor S. Schrader: Publisher

Patricia Patterson: Editor

Judith M. Mathias, RN, MA: Clinical editor

Kathy Shaneberger, RN, MSN, CNOR:Consulting editor

Paula DeJohn: Contributing writer

Karen Y. Gerhardt: Art director

OR Manager (USPS 743-010), (ISSN8756-8047) is published monthly by ORManager, Inc, 1807 Second St, Suite 61,Santa Fe, NM 87505-3499. Periodicalspostage paid at Santa Fe, NM and addi-tional post offices. POSTMASTER: Sendaddress changes to OR Manager, PO Box5303, Santa Fe, NM 87502-5303.

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Editorial


Recession’s toll on ORstaffing

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Joint Commission

The Joint Commission an-nounced in June it will look be-yond flash sterilization to take a

broader view of sterilization. Survey-ors will scrutinize the entire processrather than just focusing on whichsterilization method is selected.

“If a complete and effectiveprocess of sterilization is used, itwill be considered an effective ster-ilization method,” the commissionsaid in a June 15 update.

According to the update, sur-veyors will review the critical stepsof disinfection and sterilization, in-cluding: 1. cleaning and decontamination2. sterilization3. storage or return to sterile field.

One theme—manufacturers’ in-structions. The Joint Commissionsays surveyors will ask the staff formanufacturers’ instructions forcleaning and decontamination andwill ask how the staff is followingthe instructions. They will want to

see that steam sterilization of alltypes, including flash, meets the pa-rameters set by the manufacturers ofthe sterilizers, of wrap or packaging,and of instruments themselves.

Applause, and someconfusion

Sterilization experts say they’repleased the Joint Commissionplans to look at all steps in steril-ization but find some aspects of theupdate confusing. One issue is thedescription of flash sterilization asa cycle of “3 minutes at 270°F at 27to 28 lbs of pressure.”

The description doesn’t refer todry time, differentiate betweengravity and prevacuum cycles, normention that flash-sterilized itemsare intended for immediate use,says Rose Seavey, RN, MBA,CNOR, CRCST, CSPDT, an inde-pendent consultant and former di-rector of sterile processing.

Reconciling instructionsReconciling manufacturers’ in-

structions is another concern. It’snot always possible to reconcile in-structions for sets that require ex-tended cycles, which have becomeincreasingly common, says Cyn-thia Spry, RN, MA, MSN, CNOR,an independent consultant whochaired the working group that de-veloped the comprehensive steamsterilization standard for the Asso-ciation for the Advancement ofMedical Instrumentation (AAMI).

Sterilizer manufacturers can’tprovide instructions for some ex-tended cycles because they fall out-side the range of those that can becleared by the Food and Drug Ad-ministration (FDA).

“What’s a user to do when it’simpossible to meet these require-ments?” Spry asks.

AAMI recommends performingproduct testing for these sets, butmany facilities aren’t familiar withthat, she notes.

Reconciling instructions will be a“horrendous job,” agrees DavidNarance, RN, BSN, CRCST, managerof sterile processing for MedCentralHealth System in Mansfield, Ohio.

He makes sure to keep binderswith instructions on hand for thestaff—and makes sure they getused. He expects surveyors willask about some of the more com-plex equipment, such as powerdrills and back retractors.

Renae Battié, RN, MN, CNORRegional director of perioperative services, Franciscan Health System, Tacoma, Washington

Ramon Berguer, MDChief of surgery, Contra Costa Regional Med-ical Center, Martinez, California

Mark E. Bruley, EIT, CCEVice president of accident & forensic investigation, ECRI, Plymouth Meeting, Penn-sylvania

Jayne Byrd, RN, MSNAssociate vice president, surgical services, Rex Healthcare, Raleigh, North Carolina

Robert G. Cline, MDMedical director of surgical services, MunsonMedical Center, Traverse City, Michigan

Franklin Dexter, MD, PhDProfessor, Department of anesthesia and healthmanagement policy, University of Iowa, IowaCity

Dana M. Langness, RN, BSN, MASenior director, surgical services, Regions Hospital, St Paul, Minnesota

Kenneth Larson, MDTrauma surgeon, burn unit director, Mercy St John’s Health Center, Springfield, Missouri

Kathleen F. Miller, RN, MSHA, CNORSenior clinical consultant, Catholic Health Ini-tiatives, Denver

David A. Narance, RN, BSN, CRCSTManager, sterile processing, MedCentralHealth System, Mansfield, Ohio

Shannon Oriola, RN, CIC, COHNLead infection control practitioner, Sharp Metropolitan Medical Campus, San Diego

Cynthia Taylor, RN, BSN, MSA, CGRNNurse manager, Endoscopy & BronchoscopyUnits, Hunter Holmes McGuire VA MedicalCenter, Richmond, Virginia

Dawn L. Tenney, RN, MSNAssociate chief nurse, perioperative services,Massachusetts General Hospital, Boston

Judith A. Townsley, RN, MSN, CPANDirector of clinical operations, perioperative services, Christiana Care Health System, Newark, Delaware

Ena M. Williams, RN, MSM, MBANursing director, perioperative services, Yale-NewHaven Hospital, New Haven, Connecticut

Terry Wooten, Director, business & material re-sources, surgical services & endoscopy, St Joseph Hospital, Orange, California

Advisory Board

Surveyors to shift sterilization focus

“

“Reconciling instructions

could be horrendous.

Continued on page 6

AORN commentsAORN “applauds and supports”

the Joint Commission’s effort tobegin reviewing the whole steriliza-tion process, Ramona Conner, RN,MSN, CNOR, AORN’s manager ofstandards and recommended prac-tices, told OR Manager.

She added that AORN is “con-sidering how we can open a con-versation and talk further abouthow to clarify the statement.” Thiswould include terms used andhow surveyors plan to implementthe update.

She said AORN had discussedsterilization issues with the JointCommission last year but was notasked to review or comment on theupdate before it was released.

Need to educate staffThe broader focus means OR

managers “will have to educateeveryone in the OR and ensure allof the critical steps are met,”Seavey says.

They will need to make suresterilizers located in the OR aresubject to biological monitoringweekly and preferably daily, as rec-ommended by AAMI.

“The sterilizers in the OR willneed to be capable of running mul-tiple types of cycles. Every type ofcycle used in each sterilizer willhave to be challenged with a BIand with a Bowie-Dick type indica-tor for dynamic air-removal steril-izers,” she says.

Possible questions fromsurveyors

Managers will need to preparethe staff to respond to questionsfrom surveyors. Spry says possibleexamples are: • ”Show me the manufacturer’s in-

structions for processing these in-struments. How are you follow-ing them?”

• ”How do you know the parame-ters for this sterilization cyclewere met?” The staff should beable to show the surveyor theprintout or display from the ster-ilizer and explain how the para-meters are documented.

• ”How did you verify and docu-ment the biological and chemicalmonitoring for this instrumentset?”Seavey urges managers to be

well versed in the AORN andAAMI standards and recom-mended practices. The Joint Com-mission refers to the Guideline forDisinfection and Sterilization inHealthcare Facilities from the Cen-ters for Disease Control and Pre-vention (CDC) and Healthcare In-fection Control Practices AdvisoryCommittee (HICPAC). �

The Joint Commission update is atwww.jointcommission.org/Library/WhatsNew/steam_sterilization.htm

ResourcesAssociation for the Advancement of

Medical Instrumentation. Com-prehensive Guide to Steam Steriliza-tion and Sterility Assurance inHealth Care Facilities.ANSI/AAMI ST79:2w006. Ar-lington, VA: AAMI, 2006, 2008.www.aami.org

Rutala W A, Weber D J, et al. Guide-line for Disinfection and Steriliza-tion in Healthcare Facilities, 2008.Atlanta: CDC, 2008. (CDC/HIC-PAC guideline)www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf

Association of periOperative Regis-tered Nurses. Perioperative Stan-dards and Recommended Practices.Denver: AORN, 2009.

Spry C. Food for thought: Flashsterilization. OR Manager.2008;24:18,20. www.aorn.org

6 OR Manager Vol 25, No 8 August 2009

Joint Commission

Continued from page 5Specific activitiessurveyors willobserve

The Joint Commission sayssurveyors, among other activi-ties, will:

• Observe instruments from thetime they leave one operatingroom to when they are re-turned to the next.

• Ask health care workers toprovide manufacturers’ in-structions for instrument ster-ilization and to describe anddemonstrate how instru-ments are being cleaned anddecontaminated according tothose written instructions.

• Observe cleaning of instru-ments. “Rinsing is rarelyenough to properly removesoil from instruments; meticu-lous cleaning is needed,” thecommission says.

• Verify staff are wearing ap-propriate personal protectiveequipment.

• Observe the sterilizationprocess, including asking formanufacturers’ instructionsfor the sterilizer, wrapping orpackaging, and instruments.

• Review sterilization logs, ask-ing about parametric, chemi-cal, and biological indicators.

• Observe return of instru-ments to the sterile field andverify they are being pro-tected from recontamination.

Source: Steam sterilization: Update on the Joint Commission’sposition, June 15, 2009.www.jointcommission.org


that don’t meet the reporting re-quirement have their payment up-date reduced by 2 percentagepoints. (Requirements differ for criti-cal access hospitals.)

One new SCIP measure is re-quired for fiscal 2010, and 2 morehave been proposed for 2011.

An open bookHow hospitals are performing on

7 SCIP measures is an open book.Anyone can go to www.hospital-compare.hhs.gov to see how a hos-pital is doing on measures such asgiving the prophylactic antibiotic atthe right time and ordering treat-ments to prevent venous throm-boembolism (VTE).

The financial stick has boostedparticipation. The number of hospi-tals submitting their data “doubledovernight” when Medicare beganrequiring the reporting for a fullpayment update in 2007, says DaleBratzler, DO, MPH, president andCEO of the Oklahoma Foundationfor Medical Quality, Oklahoma City,


Continued from page 1

SCIP: Changes in national performanceAntibiotic within 60 min Guideline followed Antibiotic discontinued

for antibiotic

Deficit Reduction Actand Society ofThoracic Surgeonsrecommendation ofantibiotics for up to 48hours for cardiacsurgery

Medicare Modernization Act

*National sample of 39,000 Medicare patients undergoing surgery in US hospitals during 2001.Source: Dale Bratzler, DO, MPH, Oklahoma Foundation for Medical Quality, 2009.

Hair removal Glycemic control Normothermia

*National sample of 19,497 Medicare patients undergoing surgery in US hospitals during the first quarter of2005. Source: Dale Bratzler, DO, MPH, Oklahoma Foundation for Medical Quality, 2009.

SCIPSCIP

Continued on page 8



which manages SCIP for the Centersfor Medicare and Medicaid Services(CMS). In fiscal 2008, 97% of hospi-tals reported and received their fullupdate.

Making a difference?Is SCIP making a difference for

patients?Once public reporting started,

performance on SCIP measures im-proved markedly, Dr Bratzler says.That means more patients are re-ceiving evidence-based care:• In 2001, about 56% of Medicare

patients got an antibiotic within 60minutes of surgery. That rose to92% for the second quarter of 2008.

• In 2005, about 70% of patients had

documentation ofVTE prophylaxis.That is now closeto 90%.

Performance isalso better on gly-cemic control forcardiac surgerypatients, appro-priate hair re-moval, and nor-mothermia for co-lorectal surgerypatients (graphs).

Whether SCIPis leading to bet-ter patient out-comes is hard tosay.

When the SCIPSteering Commit-tee set the 2010

goal to reduce preventable infectionsby 25%, no formal outcome measureswere developed because of a lack offunding and other reasons.

But there are fewer deaths amongMedicare patients in the first 30 daysafter surgery, Dr Bratzler notes, witha decline of about 15% between 2004and 2007.

“I don’t necessarily attribute thereduction to SCIP, though SCIP mayhave contributed,” Dr Bratzler toldOR Manager. “A lot of things haveimproved—surgery is less invasive,perioperative care is better, anesthe-sia care is better.”

Still, he says, “surgical mortalityseems to be going down at the sametime severity of illness, complexconditions, and ages of patients aregoing up. So the trend is in the rightdirection.”

He says SCIP has also causedmore hospitals to focus on improv-ing quality, which he considers oneof SCIP’s contributions.

Caveat on ‘perfect care’What level of performance is ex-

pected on the SCIP measures?

Recommended VTE prophylaxis VTE prophylaxis received

*National sample of 19,497 Medicare patients undergoing surgery in US hospitals during the first quarter of2005. Source: Dale Bratzler, DO, MPH, Oklahoma Foundation for Medical Quality, 2009.

“

“Hospitals’ performance isan open book.

What is SCIP?The Surgical Care Improve-

ment Project (SCIP) is a nationalquality partnership of organiza-tions seeking to improve surgicalcare by reducing surgical com-plications. SCIP is guided by asteering committee representing10 organizations that havepledged their commitment andsupport:• Agency for Healthcare Re-

search and Quality• American College of Surgeons• American Hospital Association• American Society of Anesthesi-

ologists• Association of periOperative

Registered Nurses• Centers for Disease Control

and Prevention• Centers for Medicare and Med-

icaid Services• Institute for Healthcare Im-

provement• Joint Commission• Veterans Health Administra-

tion.

SCIP: Changes in national performance



For most of the measures, 90%should be achievable, and the na-tional benchmark is 99%, Dr Brat-zler notes. But the target is not 100%,he stresses.

“While many are striving for‘perfect care,’ you can only haveperfect care if you have perfect mea-sures. And we do not,” he says.

There are times a case will fail ameasure for legitimate clinical rea-sons or unforeseen circumstances(such as a drug shortage).

The fact that the target is not100% “does not excuse poor perfor-

mance—indeed target rates for mostmeasures are very high,” he says.“However, there will be legitimatereasons for a case to fail a measurethat would make an individual sur-geon’s rate less than 100%.”

Moving on to pay-for-performance?

What role SCIP and other qual-ity measures might play in an ex-panded Medicare value-based pur-chasing or pay-for-performanceprogram is a matter of speculation.Congress must act for such a pro-gram to be implemented. With the

momentum for health care reform,some observers think that couldhappen this year.

CMS suggested what formvalue-based purchasing might takein a 2007 report to Congress. In thereport, CMS proposed that a per-centage of a hospital’s DRG pay-ments be based on a combinationof its performance on quality mea-sures and its consumer satisfactionscores, with a 3-year phase-in pe-riod. Whether Congress will followthat path is yet to be seen. �

—Pat Patterson


CMS quality initiativeswww.cms.hhs.gov/

QualityInitiativesGenInfo/

Hospital CompareA government website where the

public can find and compare hospi-tals.

www.hospitalcompare.hhs.gov

Joint CommissionSCIP Core Measure set

www.jointcommission.org/PerformanceMeasurement/

PerformanceMeasurement/SCIP+Core+Measure+Set.htm

Quality improvementorganizations (QIOs)

Each state has a QIO that con-tracts with Medicare. QIOs providesupport and education on SCIP.

www.cms.hhs.gov/QualityImprovementOrgs/

QualitynetSCIP and quality measure head-

quarters on the Internet.www.qualitynet.org/

Hospital specificationsmanual

Details on reporting SCIP mea-sures are in the Specifications Man-

ual for National Hospital InpatientQuality Measures.

www.qualitynet.org/dcs/ContentServer?c=Page&pagename=

QnetPublic%2FPage%2FQnetTier2&cid=1141662756099

SCIP literature reviewwww.qualitynet.org/dcs/

ContentServer?c=OtherResource&pagename=Medqic%2FOtherResource%2FOtherResources

Template&cid=1219069853290

SCIP listservAsk questions and network with

peers. Sign up through the Quali-tyNet website.

www.qualitynet.org/dcs/ContentServer?c=OtherResource&

pagename=Medqic%2FOtherResource%2FOtherResources

Template&cid=1182785075079

SCIP tools and resourcesVisit SCIP section in QualityNet

website.www.qualitynet.org/dcs/

ContentServer?c=MQParents&pagename=Medqic%2FContent%2F

ParentShellTemplate&cid=1228694349383&parentName=Category

SCIP resourcesWhy focus onsurgical safety?• 30 million operations are per-

formed annually.• Patients who have postopera-

tive complications have dra-matically longer hospitalstays, greater mortality, andhigher costs:—Average length of stay is 3to 11 days longer.—Odds of dying within 60days increase by 3.4 fold (Sil-ber).

• Complications from surgicalerrors are costly and some-times fatal:—About 1 in 10 patients whodied within 90 days ofsurgery did so because of apreventable error; 30% ofthese deaths occurred afterdischarge. —Excess 90-day expensesrange from $646 for technicalproblems like accidental lac-erations, to $7,800 for a bloodclot or pulmonary problems,to $28,218 for acute respira-tory failure (Encinosa).

Sources: Encinosa W E, HellingerF J. Health Serv Res. 2008;43:2067-2085. Silber J H et al. MedCare. 2005;43:122-131


OR Manager asked Dale Brat-zler, DO, MPH, who coordi-nates the Surgical Care Im-

provement Project (SCIP), to re-spond to readers’ questions aboutthe project and getting all practi-tioners on board.

QWho develops the SCIP measures? Are practicing

physicians involved?

Dr Bratzler: SCIP performancemeasures are developed by Techni-cal Expert Panels, which for themost part are made up of practicingphysicians. Members also are oftenthe authors of clinical guidelines.For example, when we were devel-

oping the measuresfor antibiotic

p r o p h y -laxis, weconsultedall of the

guidelinespublished and

gathered the lead au-thors and other clinical experts. Twoexamples are E. Patchen Dellinger,MD, a recognized expert on surgicalsite infection, who is chairman ofgeneral surgery at the University ofWashington, Seattle, and Jason H.Calhoun, MD, FACS, who is nowchairman of orthopedics at OhioState University, Columbus. We alsohave infectious disease physicianson the panel.

As the measures are developed,we coordinate the process with theJoint Commission. Then the mea-sures are submitted to the NationalQuality Forum and are subject tothe NQF review process. (NQF is anonprofit organization that devel-ops consensus standards for healthcare quality.) The measures mustbe endorsed by NQF before theCenters for Medicare & Medicaid

Services will publicly report per-formance on them.

QHow do you make sure SCIP measures are up-to-date?

Dr Bratzler: That is one of thereasons we try to keep guideline au-thors on our Technical Expert Pan-els. We meet with the panels every 3months to review the measures. Weactively solicit from the guidelinedevelopers any changes they areplanning to make. We need leadtime to change the measures. If sci-ence changed today on one of theperformance measures, we can’tchange the specifications hospitalsuse for reporting until 2010.

The specifications manual forthe hospital inpatient quality mea-sures is updated every 6 monthsand posted at www.qualitynet.org.The literature backing each SCIPmeasure can be found in the man-ual.

Q Some say the SCIP measures are “cookbook

medicine.” How do you respond?

Dr Bratzler: Some may call itcookbook medicine—we call it evi-dence-based medicine. We are try-ing to reduce variation on mea-sures such as the delivery of antibi-otics for surgery, venous throm-boembolism prophylaxis, etc. I’mnot apologetic about that. Weknow there is much variationamong providers that is not ex-

plained, is not based on evidence,and doesn’t result in good out-comes of care.

We are trying to get clinicians tofollow evidence-based guidelines.For example, the SCIP measure onuse of antibiotics for prevention ofsurgical site infection was devel-oped by reviewing all of the pub-lished guidelines, which are re-markably consistent. If an antibi-otic is recommended in any of theguidelines, we include it in the per-formance measures. But if noguideline recommends an antibi-otic, we do not include it.

Keep in mind that the perfor-mance measures are not intendedto address every single case. Thereare almost 1.5 million surgical op-erations reported to the SCIP data-base every year. Occasionally, thereis legitimate reason to exclude acase or to give an antibiotic to a pa-tient that is not consistent with theperformance measure. That casewill fail the performance measurebecause we don’t have that exclu-sion built into the measure. Thus,the target rates of performance arehigh, but they are not 100% be-cause the performance measuresare not perfect.

QHow can we get all of our physicians on board with

SCIP?

Dr Bratzler: We like the approachadvocated by the Institute forHealthcare Improvement (www.ihi.org). First, you focus on the earlyadopters, those who are followingevidence-based medicine. You focuson the successes first and demon-strate improvement.

Some common themes we haveobserved that are successful:• Identify physician champions

who understand the literature

SCIP: Getting everyone on board SCIP: What’s the status?

“

“We call it evidence-based

medicine.

SCIPSCIP



and not only promote evidence-based practice but also live it.

• Use medical staff-approved pro-tocols and standardized proce-dures.

• Assign responsibilities to certainpeople. For example, to makesure the prophylactic antibiotic isgiven before the incision, someinstitutions have the anesthesiol-ogist give it. The anesthesiologistis the person who can often pre-dict when surgery will start. Thatavoids an outlier if the case is de-layed.

• Create team-based systems ofcare. ORs already perform thetime-out before surgery forsurgical site verification. Dur-ing the time-out, many have in-corporated the question: “Wasthe antibiotic delivered?” Thenit is not just the surgeon whohas to remember the antibiotic.It is part of the standard proto-col.

• Provide physician profiles.Some organizations providefeedback on the SCIP measuresat the physician level. Some doit through confidential reports.Others are more open, perhapsposting a chart in the physi-cians’ lounge so everyone cansee where everyone else stands.If there are still physicians who

hold down the institution’s rates,some hospitals include perfor-mance on SCIP measures in thephysician’s credentialing file. Itbecomes part of the credentialingprocess.

I think many hospital adminis-trators and boards understandthat eventually performance onthese measures is in some waygoing to be tied to payment. Atsome point in the future, theywon’t be able to tolerate a physi-cian who won’t participate in evi-dence-based performance mea-sures. �

Surgical Care Improvement Project measures Inpatient measures applicable to acute care hospitals

Fiscal 2010 Fiscal 201110/01/09-03/31/10

Reporting Proposed required for for required

Measure annual pay update reporting

Infection

SCIP-Inf-1: Prophylatic antibiotic X Xreceived within 1 hour of incisionSCIP-Inf-2: Prophylactic antibiotic X Xselection for surgical patientsSCIP-Inf-3: Prophylactic antibiotic X Xdiscontinued within 24 hours after surgery end time (48 hours for cardiac surgery)

SCIP-Inf-4: Cardiac surgery patients X Xwith controlled 6 am postoperative blood glucose

SCIP-Inf-6: Surgery patients with X Xappropriate hair removal

*SCIP-Inf-7: Colorectal surgery patients with immediate postoperative normothermia

SCIP-Inf-9: Urinary catheter removed **Xon postoperative day 1 or postoperative day 2 with day of surgery being day 0

SCIP-Inf-10: Surgery patients with **Xperioperative temperature management

Cardiac

SCIP-Card-2: Surgery patients on beta-blocker X Xtherapy prior to arrival who received a beta-blocker during perioperative period

VTE

SCIP-VTE-1: Surgery patients with X Xrecommended venous thromboembolism prophylaxis orderedSCIP-VTE-2: Surgery patients who received X Xappropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery

*Data collection to be discontinued 4Q 2009.**Proposed for FY 2011 payment determination in IPPS proposed rule, May 1,2009.


One more SCIP measure isadded for reporting for fiscalyear 2010. Two more are

proposed for fiscal 2011 as part ofthe Surgical Care Improvement Pro-ject (SCIP).

Beginning Oct 1, 2009, the start ofFY 2010, one more measure will af-fect hospitals’ Medicare paymentupdate: Surgical patients on a beta-blocker prior to arrival who received

a beta-blocker duringthe periopera-

tive period(SCIP Car-diovascu-l a r - 2 ) .

Hospitalsstarted sub-

mitting data on thismeasure at the beginning of 2009.

The 2 measures proposed for re-porting to receive the full paymentupdate in FY 2011 are: • removal of postoperative urinary

catheter• postoperative normothermia for

all surgery.The measures were proposed in

the draft 2011 hospital inpatientprospective payment rule releasedMay 1, 2009, by the Centers forMedicare and Medicaid Services.

A possible future measure is theintraoperative redosing of antibi-otics.

Perioperative beta-blockersThe beta-blocker measure has

been the subject of some contro-versy. The measure is based on aClass I recommendation from theAmerican College of Cardiology(ACC)/American Heart Association(AHA) 2007 guidelines. The guide-lines recommend continuing beta-blockers in patients having surgerywho receive those beta-blockers forangina, arrhythmia, hypertension,

or any other Class I indication speci-fied in the guideline.

The benefits versus harm of peri-operative beta-blockers have beendebated, and further studies havebeen published. The ACC and AHAare updating their guideline, andthe revision may be published thisyear, notes Dale Bratzler, DO, MPH,SCIP’s medical director. “But cur-rently, this is a Class I recommenda-tion: If the patient is on a beta-blocker prior to admission, simplydon’t stop it.”

Another discussion focuses onthe POISE study published in 2008,which randomized 8,351 patientswith atherosclerotic disease havingnoncardiac surgery to receive a peri-operative beta-blocker or placebo.The international multicenter trialpublished in Lancet found fewer pa-tients in the beta-blocker group hada myocardial infarction than those inthe placebo group, but there weremore deaths and strokes among pa-tients receiving beta-blockers. Theauthors called for a larger random-ized trial.

Dr Bratzler said the POISE studydoes not affect the SCIP measure be-cause the POISE results do notapply to patients already takingbeta-blockers at home beforesurgery; those patients were ex-cluded from the study. Moreover, hesays, another study by Hoeks et alfound that when beta-blockers were

stopped abruptly, surgical mortalityincreased.

Urinary catheter useSCIP Infection 9: Urinary catheter

removed on postoperative day 1 or post-operative day 2, with the day of surgerybeing day zero.

This proposed measure is basedon a study reported in 2008 by HeidiL. Wald and colleagues involving35,900 Medicare patients havingmajor surgery. Of these, 86% had in-dwelling urinary catheters, and 50%of those still had their catheters 2days postoperatively. These patientswere twice as likely to develop a uri-nary tract infection (UTI) as patientswho had catheters for 2 days or less.Patients who developed a UTI weremore likely to die within 30 days ofsurgery.

Another study by Sanjay Saint etal found 56% of hospitals did nothave a system for monitoring whichpatients had urinary catheters, and74% did not monitor catheter dura-tion.

Excluded from the SCIP measurewould be patients who had urologi-cal, gynecological, or perineal opera-tions and patients whose physiciandocuments a reason not to removethe catheter. On postop day 1 or 2,there must be evidence of an at-tempt to remove the catheter. Themeasure has been endorsed by theNational Quality Forum (NQF).

Surgical normothermiaSCIP Infection 10: Proportion of

patients undergoing any operation(any age) under anesthesia for 60 min-utes or more who have active warmingdevices used or have at least one bodytemperature of 96.8° F/36 C° recordedwithin 30 minutes immediately priorto or the 15 minutes immediately after


New SCIP measures being introduced

SCIPSCIP“

“50% still hadcatheters 2 days

postop.



anesthesia end time. Excludes patientswith intentional hypothermia.

This proposed new measurewould replace SCIP Infection 7,which applies to normothermia forcolorectal surgery patients.

“There is strong support to keeppatients warm in the operatingroom,” Dr Bratzler says. Patientswho are hypothermic are at risk forcomplications such as acute myocar-dial infarction, arrhythmias, coagu-lopathy, and surgical site infections.

The measure is aligned with aphysician performance measurefrom the American Society of Anes-thesiologists. The measure has beenendorsed by NQF.

Redosing of antibioticsA possible future SCIP measure

would call for an additional dose ofthe prophylactic antibiotic within 4hours of the preoperative dose forpatients who receive a short half-lifeantibiotic (cefazolin, cefuroxime, ce-foxitin, or ampicillin-sulbactam) andare still in surgery more than 4hours after the start time of the pre-operative antibiotic dose. This mea-sure has not yet been endorsed byNQF and has not yet been proposedfor reporting to CMS.

The basis for the proposal is evi-dence that when a single dose of ashort half-life antibiotic is given, lev-els of the drug fall off rapidly.

“If you give a single preoperativedose of a drug like cefazolin, and youhave a long operation, once you getto 3 or 4 hours, there is no antibioticleft in the tissue—it’s all in the Foleycatheter,” Dr Bratzler says. This hasbeen demonstrated in tissue biopsiesby DiPiro and other researchers.

A related issue that is not part ofthe SCIP measures at present isweight-based dosing of antibiotics.“Underdosing is one of the mostcommon errors in surgical antimicro-bial prophylaxis,” Dr Bratzler says.

He noted that some institutionsuse higher doses of antibiotics forpatients who are morbidly obese.

“Drugs such as cefazolin are verysafe, reactions are uncommon, andunderdosing for large patients isprobably common,” he says. �

For a full description of SCIP measures,reporting specifications, and supportingliterature, see the Specifications Manualfor National Hospital Inpatient Qual-ity Measures at www.qualitynet.org

ReferencesDevereaux P J, Yang H, Yusuf S, et al.

Effects of extended-release meto-prolol succinate in patients under-going non-cardiac surgery (POISEtrial). Lancet. 2008;371:1839-1847.

Fleisher LA, Beckman J A, Brown KA, et al. ACC/AHA guidelines onperioperative cardiovascular eval-uation and care for noncardiacsurgery. J Am Coll Cardiol.2007;50:e159-242.

Hoeks S E, Scholte op Reimer W J, vanUrk H. Increase of 1-year mortalityafter perioperative beta-blockerwithdrawal in endovascular andvascular surgery patients. Eur JVasc Endovasc Surg. 2007;33:13-19.

Saint S, Kowalski C P, Kaufman S R, etal. Preventing hospital-acquiredurinary tract infections in theUnited States: A national study.Clin Infect Dis. 2008;46:243-250.

Wald H L, Ma A, Bratzler D W, et al.Indwelling urinary catheter use inthe postoperative period. ArchSurg. 2008;143:551-557.

Outpatient payrule proposedfor 2010

The Centers for Medicare andMedicaid Services (CMS) onJuly 1 issued its proposed

2010 outpatient payment rule. Therule, to be effective Jan 1, 2010, ap-plies to hospital outpatient servicesand ambulatory surgery centers(ASCs). Comments are accepteduntil Aug 1. The final rule is to be is-sued by Nov 1.

In highlights:• The hospital outpatient inflation

update is projected at 2.1%. • The ASC conversion factor up-

date would be 0.6%.• Quality reporting:

—In 2010, hospitals would con-tinue reporting on 11 outpatientmeasures. These include 2 surgi-cal measures: prophylactic antibi-otic given within 1 hour of surgi-cal incisions and prophylactic an-tibiotic selection for surgical pa-tients. —For 2011, CMS is not proposingto add any new quality measuresto qualify for the full Medicarepayment update.

• CMS is seeking comment on po-tential future quality measures.

ASC proposalsASCs will continue their transi-

tion to the new Medicare paymentsystem, which is pegged to hospi-tal outpatient rates. • ASCs would not be required to

participate in quality reportingin 2010.

• 28 procedures would be addedto the list of allowed ASC proce-dures.An analysis of the proposal’s

impact on ASCs, with a rate calcu-lator, is on the ASC Association’swebsite at www.ascassociation.org/medicare2010. �

The proposed rule is posted at www.ascassociation.org/medicare2010/

“

“There is strongsupport to keeppatients warm.



SCIP: VTE prevention controversy

An orthopedic surgeon an-nounces she is revising herorders to call for aspirin as

the sole prophylaxis for venousthromboembolism (VTE) for herpatients having total joint replace-ment who are at a standard risk for

both pulmonarye m b o l i s m

(PE) andbleeding.She refersto guide-

lines fromthe American

Academy of Orthopaedic Surgeons(AAOS).

Alarm bells go off for the ORmanagement team. Under the Sur-gical Care Improvement Project(SCIP), aspirin alone does not meetthe SCIP VTE 1 measure for pa-tients with no documented risk ofbleeding.

Issues like these have arisen asphysicians and OR leaders weighthe evidence on VTE preventionfor orthopedic surgery.

The role of aspirinThe SCIP VTE measures do not

allow aspirin alone for patients atstandard risk of PE and bleeding.That is because there is a Grade 1Arecommendation against aspirinalone for all surgical patients fromthe American College of ChestPhysicians (ACCP) guidelines, onwhich the SCIP measures arebased. (Grade 1A is a strong rec-ommendation supported by highquality evidence.)

One solution: If the surgeon isconcerned about bleeding, and riskfactors for bleeding are docu-mented in the chart, the surgeoncan use mechanical prophylaxis forthe patient, and that will pass theSCIP measure, notes Dale Bratzler,

DO, MPH, of the Oklahoma Foun-dation for Medical Quality, whichsupports SCIP for CMS. Mechani-cal prophylaxis is recommendedby both ACCP and AAOS. If thesurgeon wants to give the patientaspirin or warfarin in addition, thecase will still pass the SCIP mea-sure, Dr Bratzler says. Aspirin usedalone, however, will not pass themeasure.

(A summary of the recommen-dations is in the sidebar.)

Role of mechanicalprophylaxis

Updated AACP guidelines re-leased in 2008 give a more promi-nent role to mechanical prophy-laxis than the 2004 guidelines onwhich the SCIP measures werebased. ACCP now recommendsmechanical prophylaxis with a ve-nous foot pump or intermittentpneumatic compression device forpatients having total joint replace-ment and hip fracture procedureswho have a high risk of bleeding.

The AAOS guidelines advocatemechanical compression devicesand early mobilization in all pa-tients. AAOS also says aspirinwould not be the lone thrombopro-phylaxis measure, Norman Johan-son, MD, chairman of the groupthat developed the AAOS guide-lines, told OR Manager.

“Aspirin alone is not really ac-ceptable to anybody,” he says, not-

ing that the issue really is not useof aspirin alone but its use withmechanical prophylaxis.

Weighing the risksIn deciding on VTE prophylaxis,

physicians must weigh the risks ofDVT and PE with the risk of bleed-ing, both serious complications forsurgical patients.

Orthopedic surgeons say theAAOS guidelines, which focus onprevention of symptomatic PE, aremore applicable to orthopedic surgi-cal patients. The ACCP guidelinesfocus on both asymptomatic andsymptomatic DVT as an outcome.

Orthopedic surgeons contendthat the aggressive prophylaxis rec-ommended by ACCP raises therisk of major bleeding.

“The ACCP guidelines lump allorthopedic surgery into a high-riskgroup [for VTE] and give incidenceof DVT in the 50% to 60% range.Orthopedic surgeons know the in-cidence is nowhere near that high,”Dr Johanson says. “The incidenceof symptomatic PE for hip replace-ment is less than 1%, and it is farless than 1% for knee replacement,whereas the incidence of bleedingwith aggressive prophylaxis is upto 4%,” says Dr Johanson, who ischairman of the Department of Or-thopedic Surgery at Drexel Univer-sity College of Medicine in Phil-adelphia.

Risk of bleedingBleeding is a major concern in

orthopedic patients, and he saysmore research on postoperativebleeding is needed. “This is a pa-tient safety issue—a patient can beharmed by a drug that causes post-operative bleeding,” says Dr Jo-hanson.

The reason there hasn’t been


“

“Bleeding is a major concern.

SCIPSCIP

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more research is that it is difficultto define major bleeding, he notes.Some surgeons take patients backto the operating room, while otherswait to see if the bleeding stops.With every major hematoma, par-ticularly in and around the knee,he says, there is a higher risk ofdrainage, which raises the risk ofinfection and further problems.

Risk of DVT, PESurgery is also one of the

biggest risk factors for DVT andPE, Dr Bratzler points out. The riskis almost 25-fold greater for surgi-cal patients than for patients whoare not in the hospital, according topublished research.

He says most experts who par-ticipated in developing the SCIPmeasures think patients havingtotal joint procedures are all atsignificant risk of VTE, and riskstratification is not needed. Thefact that the AAOS guidelines donot discuss the risk of DVT orasymptomatic PE is a problem, hesays.

“Based on studies of patientswho survived DVT or PE, 30%have recurrence within 10 years,and 28% will develop deep venousstasis syndrome within 20 years. Sowe think asymptomatic DVTs andPEs do present a risk for long-termcomplications.”

Dr Johanson responds, “Post-thrombotic syndrome among totaljoint patients who did not previ-ously have some form of venousstasis disease has never beenproven to be a problem and, in myopinion, needs more careful re-search to identify it as a significantclinical issue.”

Stratifying riskAnother issue is that, though the

AAOS guidelines advocate riskstratification for each patient, there

are currently no good evidence-based guidelines for risk stratifica-tion, Dr Johanson notes.

Dr Bratzler says stratifying pa-

tients when there is no evidence-based risk stratification system es-sentially means no one really


Comparison of AAOS and SCIP on VTE prophylaxis Summary: American Academy of Orthopaedic Surgeons (AAOS)Clinical Guideline on Prevention of Symptomatic PulmonaryEmbolism in Patients Undergoing Total Hip or Knee Arthroplasty

Standard risk PE, standard riskbleeding*AspirinLMWHSynthetic pentasaccharidesWarfarinLevel III, Grade B recommendation

Elevated risk PE, standard riskbleedingLMWHSynthetic pentasaccharidesWarfarinLevel III, Grade B recommendation

Standard risk PE, elevated riskbleedingAspirinWarfarinNoneLevel III, Grade C recommendation

Elevated risk PE, elevated riskbleedingAspirinWarfarinNoneLevel III, Grade C recommendation

Additional notes about AAOS recommendations:1. “The risk of PE differs among different patients; however, there is currently nosatisfactory evidence-based risk stratification system.” (p 12).2. Recommendation 1.2: All patients should be assessed preoperatively for elevatedrisk (greater than standard risk) of major bleeding (Level III, Grade C). Note: Gradeof recommendation reduced because of lack of consistent evidence on riskstratification of patient populations.3. Recommendation 2.1: Patients should be considered for intraoperative and/orimmediate postoperative mechanical prophylaxis (Level III, Grade B).4. Recommendation 3.1: Postoperatively, patients should be considered forcontinued mechanical prophylaxis until discharge to home (Level IV, Grade C).

SCIP VTE 1 Performance Measure: Hip or knee arthroplasty

No bleeding risk documentedLMWHSynthetic pentasaccharidesWarfarinKnee arthroplasty only:

Intermittent pneumatic compression devices Venous foot pump

Documented bleeding riskMechanical prophylaxis[Any other modality (including aspirinor warfarin) can be added at thediscretion of the surgeon.]

*This is the ONLY category where there is a significant difference between therecommendations of the AAOS and the national SCIP performance measure. TheAAOS guideline recommends aspirin alone for those patients who are at “standardrisk of both PE and major bleeding.”

Source: Surgical Care Improvement Project, Dale Bratzler, DO, MPH, 2009.



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knows how to divide patients intostandard or elevated risk.

Strength of the evidenceThe strength of the evidence

backing the guidelines is anotherissue. All of the AAOS recommen-dations for pharmacoprophylaxisare supported by Level 3 evidence,which is not as strong as AACP’sGrade 1 recommendations, DrBratzler notes. Level 3 evidence isbased on case-control studies.

Dr Johanson says the AAOS rec-ommendations rely on Level 3 evi-dence because the literature onpulmonary embolism is not strongowing to the large sample size thatwould be required. The literature isthe same as that examining DVT asan end point. Because the inci-dence of DVT is higher than the in-cidence of PE, the studies are moreappropriately powered to answerquestions about DVT incidence, henotes.

“If you have DVT incidence of9% or 10%, and you want to provea 50% risk reduction, your samplesize needs to be 200 to 300 patients;whereas, if you want to achieve a50% risk reduction of a PE inci-dence of 0.8%, you need 35,000 pa-tients,” Dr Johanson explains.

Returning to the aspirin issue,Dr Bratzler summarizes: “Any sur-geon who is concerned aboutbleeding can put mechanical pro-phylaxis on the patient, and thecase will pass the performancemeasure. Then if they want to useaspirin, that isn’t counted againstthem [for SCIP].”

He and Dr Johanson agree thatdespite the controversy, the ortho-pedic surgeons are some of the bestphysicians at following the SCIPperformance measures. �

—Judith M. Mathias, RN, MA

ReferencesAssociation of periOperative Regis-

tered Nurses. AORN Guidelinefor Prevention of Venous Stasis.Perioperative Standards and Recom-mended Practices. Denver: AORN,2009.

Bratzler D. Patient Safety and theSurgical Care Improvement Pro-ject. Feb 2, 2009; Presentation atthe Colorado Foundation forMedical Care, Englewood. Webi-nar available at:www.cfmc.org/files/hospital/Great8_SCIP%200209%201%20slide%20per%20page.pdf

Geerts W H, Bergquist D, Pineo G F,et al. Prevention of venousthromboembolism: AmericanCollege of Chest Physicians evi-dence-based clinical practiceguidelines (8th edition). Chest.2008;133:381s-453S.www.chestjournal.org/content/133/6_suppl/381S.full.pdf+html?sid=0ad15ea7-d1f5-458a-9b1c-b0085f4b9079

Geerts W H, Pineo G F, Heit J A, etal. Prevention of venous throm-boembolism: The seventh ACCPconference on antithromboticand thrombolytic therapy. Chest.2004;126:338S-400S.www.chestjournal.org/content/126/3_suppl/338S.full.pdf+html?sid=b2092ed0-9244-4748-98c3-db99b7481aca

Johanson N A, Lachiewicz P F,Lieberman J R, et al. Preventionof symptomatic pulmonary em-bolism in patients undergoingtotal hip or knee arthroplasty. JAm Acad Orthop Surg. 2009;183-196. www.aaos.org/research/guidelines/PE_guideline.pdf


“

“Aspirin alone is not acceptable.

Continued from page 16Preventing VTE:Stockings orpumps. What’s thebest method?

Guidelines recommend usingmechanical methods to preventvenous thromboembolism (VTE).

But what type is best to use?Options include compressionstockings like TED hose and se-quential compression devices(SCDs). Both come in knee-highand thigh-high lengths, and SCDsalso come as foot pumps.

Unfortunately, there aren’t clearanswers about what’s best. Butwhatever the method, they mustbe fitted and used correctly.

The Surgical Care ImprovementProject (SCIP) says either knee-high or thigh-high SCDs or com-pression stockings are acceptable.

The American Academy of Or-thopaedic Surgeons guideline rec-ommends mechanical compres-sion for total hip and total knee re-placement unless it is contraindi-cated. But the guideline notes noprospective randomized studieshave compared the efficacy ofthese devices.

The American College of ChestPhysicians (ACCP) 2008 VTE pre-vention guideline says mechanicalmethods have advantages in pa-tients with high bleeding risk buthave not been studied as much asanticoagulants. Many of these de-vices have not been studied inclinical trials, and companies donot have to demonstrate they areeffective in preventing VTE tomarket them, ACCP notes.

ACCP urges clinicians to selectthe correct size, properly applythem, and remove them only for ashort time each day when the pa-tient is walking or bathing.


fred Casale, MD, FACC, associatechief medical officer for Geisinger,says ProvenCare’s success is basedon 5 elements: “appropriateness ofcare, adoption of best practices, re-design and re-engineering of day-to-day processes to be sure bestpractices are reliably delivered toevery patient, patient activation,and treating the patient as an inte-gral member of the team.” DrCasale is also director for cardio-thoracic surgery and co-director ofthe Geisinger Heart Institute.

Track recordGeisinger introduced the CABG

program in February 2006. (SeeAugust 2007 OR Manager).

Like most cardiac surgery pro-grams, Geisinger found variabilityin care delivery and wanted to im-prove outcomes by reducing thatvariability. In addition to betteroutcomes, ProvenCare has finan-cial benefits. The CABG programcut costs by 15% and reducedlength of stay by 0.5 days becauseof fewer complications.

“We hoped that by hitting everystep every time, we would posi-tively affect clinical outcomes,”says Dr Casale. “But we were sur-prised that eliminating variabilityalso had a financial benefit.”Geisinger plans to publish out-comes for the total hip replacementand perinatal programs.

Developing the programsGeisinger developed a specific

process for implementing a newProvenCare program (sidebar, p 20).

“We get the physicians involvedfrom the beginning in adoptingguidelines and translating theminto measurable best practices weall feel comfortable with and thatare appropriate,” says Dr Casale.



Preadmission Indication for cataract surgeryPreop consentPatient's own assessment of visual acuity obtainedAssessment of visual acuityAssessment of intraocular pressure (IOP) (tonometry)Assessment of current spectacle correctionAssessment of best corrected visual acuity (with glasses or pinhole)Patient received external eye exam (lids and adnexa)Assessment of ocular alignment and motilityAssessment of pupilsPatient received slit lamp exam of anterior segmentPatient received dilation exam of lens, vitreous fundus, and optic nerve/disc(funduscopic)Intraocular lens (IOL) calculations & method, axial length & corneal powermeasurementAlternative causes of decreased visual acuity

Operating roomPatient received operative topical antibiotic (preoperative note)Patient received operative 5% povidone iodine

Postdischarge: First clinic visitDiscussion and documentation of interval historyPatient's own assessment of visual functional statusDiscussion of patient's compliance with postop regimenMeasurement of visual acuityAssessment of IOP (surgeon)Patient received slit lamp examPatient received counseling and educationDiscussion of management plan

Postdischarge: Second clinic visitDiscussion and documentation of interval historyPatient's own assessment of visual functional statusDiscussion of patient's compliance with postop regimenMeasurement of visual acuityAssessment of IOP Patient received slit lamp examPatient received counseling and educationDiscussion of management plan

Postdischarge: Third clinic visitDiscussion and documentation of interval historyPatient’s own assessment of visual functional statusDiscussion of patient's compliance with postop regimenMeasurement of visual acuityPatient received slit lamp examPatient received counseling and educationDiscussion of management plan

Courtesy Geisinger Health System.

ProvenCare cataract process measures90-day guarantee


For example, for CABG, each ofthe 40 best practices/benchmarksfrom the American College of Car-diology and American Heart Asso-ciation are hardwired into ordersets or notes.

“Much of the step-by-step processoccurs before and post surgery, so itisn’t a radical difference in the OR,”says Stella Gebhardt, RN, director ofsurgical services for GeisingerNortheast.

“OR nurses who routinely workwith several cardiac surgeons saythe consistency is very helpful,”she adds.

Part of establishing a new pro-gram is defining “related” compli-cations. Examples are sternalwound infection and heart failurefrom a perioperative myocardialinfarction. Unrelated complicationswould be diverticulitis, hip frac-ture, and pre-existing heart failure.

Physician buy-inGeisinger employs 740 physi-

cians, which one might expectmakes it easier to implement newProvenCare programs.

“Certainly, functioning within alarge, integrated group practicewith a pattern of behavior that em-phasizes practicing for the com-mon good as opposed to individ-ual prerogative is valuable,” saysDr Casale. But all physicians don’tpractice uniformly, so there arechallenges.

“In the CABG process, we werelucky we had surgeons who werealready focused on quality im-provement and minimizing unnec-essary variation,” says Dr Casale.“Even with all that commitment,we still had huge opportunities tooptimize our process of care.”

Each successful program helpsease the process. “Physicians rec-ognize that program adoption isnetting better outcomes,” he says.

Patient buy-inGeisinger serves 43 of Pennsyl-

vania’s 67 counties—2.6 millionpeople. The system knew active,engaged patients would contributeto better outcomes. A Patient Com-pact, which the patient and physi-cian agree on, addresses commit-ment from both parties, includingthe patient’s agreement to makelifestyle changes. Patient educationmaterial is congruent with Proven-Care concepts. Patients receive cus-tomized instruction letters andtrend reports as appropriate.

Monitoring complianceGeisinger monitors compliance

in “real time” through its electronichealth record (EHR). “In cases

where the process isn’t followed orin near misses, feedback is gener-ally provided the same day,” saysDr Casale. “This makes folksaware we are serious, cooperationis important, and we are watch-ing.”

But he says ProvenCare pro-gram started with “pencil andpaper, so it’s possible to make thiswork without an EHR.”

Scope of serviceCurrently, ProvenCare is part of

the Geisinger Health Plan, whichhas 225,000 members, including 90non-Geisinger hospitals and about25,000 providers who participate inthe plan’s network. Geisinger isworking to entice other insurers toparticipate. Hospital adoption hasbeen slow because administratorsbelieve they will lose money fromnot being able to bill for patientswho are readmitted. That maysoon change.

ProvenCare’s evidence-basedbundling of care is in line with ef-forts to reform health care. TheObama administration is pushingfor bundling Medicare paymentsto hospitals and physicians for pro-cedures such as CABG and notpaying for complications. Medicarehas already said it will stop payingfor some preventable complica-tions. As reimbursement tightens,the consistency and positive out-comes of ProvenCare are likely togain appeal. �

—Cynthia Saver, RN, MS

Cynthia Saver is a freelance writer inColumbia, Maryland.

ReferencesA health system’s experiment with

a 90-day warranty for CABG. ORManager. 2007;23(8):1, 8-10.

For this health system, less is more.Washington Post, March 31, 2009,A01.



“

“There are better outcomes

and financialbenefits.

Developing aProvenCareprogram• Identify high-volume DRGs.• Obtain leadership commit-

ment.• Identify best practices.• Review existing workflows.• Review stakeholder align-

ment.• Determine reporting metrics.• Redesign processes.• Ensure process reliability.• Analyze financial modeling,

global pricing, and pay forperformance.

• Maintain and monitor.



OR business management

‘Never events’: Sorting out confusion

There’s a lot of discussionabout Medicare no longerpaying for “never events.”

Surprisingly, so far, the policy hashad little financial impact. Until re-cently, Medicare hadn’t given in-structions about how claims forthese events should be handled.There is also confusion about howMedicare defines a “never event”for payment purposes. OR Managerasked Keith Siddel, MBA, an ex-pert on health care business opera-tions, to respond to frequent ques-tions. He is CEO of HRM Consult-ing, Creede, Colorado.

Q How does Medicare define a “never event”? How does

that differ from a HAC?

Siddel: There has been a lot ofconfusion about “never events”versus what Medicare calls “hospi-tal-acquired conditions,” now to becalled health care-acquired condi-tions, or HACs.

“Never events” were originallydeveloped by the National QualityForum as a list of 28 preventableevents that should never happen topatients. Payers began saying, “Ifthese are serious mistakes, weshouldn’t be paying for them.”

Congress took action in 2005,and from that Medicare began de-veloping 2 programs for nonpay-ment of serious events:• Never events. Currently, there are

only 3 “never events” Medicarewill not pay for: Surgery on thewrong body part, surgery on thewrong patient, and wrong sur-gery on a patient. Medicare re-cently issued national coveragedeterminations (NCDs), or na-tional payment policies, for these3 events. The NCDs went into ef-fect July 6, 2009, for physicians

and will go into effect October 1,2009, for hospitals. They areposted at www.cms.gov (140.7,140.8, and 140.9). The NCDs ex-plain specifically how Medicaredefines these events.

• HACs. For fiscal 2009, there are10 categories of HACs for whichMedicare announced it wouldreduce the DRG payment (side-bar, p 22). HACs have relatedICD-9 codes and are determinedusing POA (present on admis-sion) indicators. Examples areforeign objects retained aftersurgery, pressure ulcers, andcertain types of surgical site in-fections. Medicare has said itwill not provide additional pay-ment for HACs if they are notpresent on admission.

Q If we have a “never event,” how do we handle the

claim? Do we write off thepatient’s entire bill?

Siddel: Until recently, that was-n’t clear. Medicare just clarified itsprocess in June 2009.

First, Medicare has defined morespecifically what these wrong proce-dures are, and I think it opens thedoor for a wider interpretation. TheMedicare policy says: A surgical orother invasive procedure is consid-ered to be the wrong procedure “if itis not consistent with the correctlydocumented informed consent for

that patient.” There are a few excep-tions, such as emergencies.

So they will really be comparingthe procedure performed to the in-formed consent. That is how theywill decide if it’s the wrong proce-dure. That means hospitals and ORpersonnel need to make sure theconsent matches the procedureperformed.

Filing a claimMedicare recently spelled out

the process for claims for these 3never events. For inpatients, 2claims need to be filed. The firstclaim has the covered services un-related to the erroneous surgery.The second, completely distinctclaim has all the services that wereerroneous—that is a no-pay claim.On the no-pay claim, in the com-ment section, the hospital wouldput a 2-digit code:

MX: Wrong surgery on a patientMY: Surgery on wrong body partMZ: Surgery on wrong patient.

For outpatients, the facilitywould append one of the follow-ing modifiers to the HCPCS code:

PA: Surgery on the wrong body partPB: Surgery on the wrong patientPC: Wrong surgery on a patient.

Related claimsAnother big change: Medicare

has instructed its contractors (ie,fiscal intermediaries and MACs) toreview all beneficiary claims re-lated to these wrong-surgeryevents every 30 days for 18months. If there are any relatedclaims, the contractor is to “takeappropriate action.” In otherwords, once a patient has had asurgical error, the contractor willlook for related claims and denythese claims as appropriate.


“

“Medicare justclarified its

process.


OR business management

But once again, Medicare’s in-structions are incomplete. What ifthe patient has a wrong surgery atHospital A but goes to Hospital Bfor follow-up care? Does that meanthe contractor will deny paymentto Hospital B? We need more clari-fication on that.

QWhat about payment for HACs? How is that

affecting hospitals?

Siddel: Not as much as you mightthink. The way it works is that forthese conditions, Medicare and someother payers will look for a POA,which stands for “present on admis-sion.” Thus, if a patient has a Stage 3or 4 decubitus ulcer on admission,and the POA is recorded incorrectlyas no, the payer will consider it aHAC. When processing the claim,Medicare will ignore the code for the

decubitus ulcer when calculating allof the codes to make up the DRG.

But for 90% of patients who havea HAC, this actually doesn’t makemuch difference in the payment.Why? Most patients who haveHACs have such complex condi-tions that just pulling out the codefor the HAC doesn’t have much of anet effect on the DRG payment.

Medicare will have to change thisin the future. It is not doing what theywanted it to do, which is to reduce thepayment. We expect them to changeit, perhaps as soon as next year. �


Keith Siddel will presenttwo webinars:

Sept 17: Improving the ORRevenue Cycle

Oct 1: Taming the ChargeDescription MasterTo register, go to

www.ormanager.com

These are summaries of Medi-care’s definitions of wrong surgeryfor nonpayment purposes. See thenational coverage determinationsfor complete wording.

Wrong surgical procedureperformed on a patient

“A surgical or other invasive pro-cedure is considered to be thewrong procedure if it is not consis-tent with the correctly documentedinformed consent for that patient.”

Exceptions: Emergencies andchanges in the surgical plan due tocertain circumstances spelled out inthe manual.

Surgery on wrong body part

“Asurgical or other invasive pro-cedure is considered to have beenperformed on the wrong body partif it is not consistent with the cor-

rectly documented informed con-sent for that patient, including sur-gery on the right body part but onthe wrong location of the body” (eg,left versus right appendages or or-gans) or at the wrong level (spine).

Exceptions: Emergencies andchanges in the surgical plan due tocertain circumstances spelled out inthe manual.

Surgery on wrong patient“A surgical or other invasive pro-

cedure is considered to have beenperformed on the wrong patient ifthat procedure is not consistentwith the correctly documented in-formed consent for that patient.”

Source: CMS. National Coverage Determination. Manual Section Number 140.6, 140.7, 140.8. www.cms.hhs.gov/center/coverage.asp

Medicare defines wrong surgeryTen categories of HACs1. Foreign object retained after

surgery 2. Air embolism 3. Blood incompatibility 4. Stage 3 and 4 pressure ulcers 5. Falls and trauma

• Fractures • Dislocations • Intracranial injuries • Crushing injuries • Burns • Electric shock

6. Manifestations of poor glycemiccontrol • Diabetic ketoacidosis • Nonketotic hyperosmolar

coma • Hypoglycemic coma • Secondary diabetes with

ketoacidosis • Secondary diabetes with

hyperosmolarity7. Catheter-associated urinary tract

infection (UTI) 8. Vascular catheter-associated in-

fection 9. Surgical site infection following:

• Coronary artery bypass graft—mediastinitis

• Bariatric surgery —Laparoscopic gastric bypass —Gastroenterostomy —Laparoscopic gastric

restrictive surgery• Orthopedic procedures —Spine —Neck —Shoulder —Elbow

10. Deep vein thrombosis/pul-monary embolism• Total knee replacement • Hip replacement

Source: Centers for Medicare and Medicaid Services. www.cms.hhs.gov/HospitalAcqCond/06_HospitalAc-quired_Conditions.asp#TopOfPage


Engaging your staff in hard timesManaging people

An engaged workforce ismore important than everin the hard economic times

facing OR managers and their fa-cilities, says Jo Manion, RN, PhD,FAAN, NEA-BC, an author andmanagement consultant.

“A positive manager asks, ‘Howcan we use this challenge?’” Man-ion told OR Manager in a June in-terview. Her new book, The En-gaged Workforce: Proven Strategies toBuild a Positive Health Care Work-place, was just published.

Learning and reinforcing profes-sional competence do not stop be-cause budgets are being cut, shesays. “It means being willing to trysomething you haven’t tried.”

Positive psychologyWith decreased vacancy rates

and staff members just grateful tohave a job, having an “engagedworkforce” might seem easy, Man-ion says, and that is not necessarilythe case. Staff may still face eco-nomic stresses as spouses’ incomesare slashed or lost, benefits are cut,and job stability is less certain.

“Just having a job doesn’t makethe other problems go away,” Man-ion says. “And let’s face it, somepeople might be making otherchoices if they weren’t bound byeconomic needs. Nurses mighthave planned to retire or move intoother part-time work but feel theyhave to stay on the job longer. Thatfeeling of being trapped doesn’tmake them more enthusiastic.”

An engaged workforce—staffwith enthusiasm and commitmentin their work lives, teams, and or-ganization—is more importantthan ever, Manion says. One wayto create that workforce is throughthe application of positive psychol-ogy, a field that she has written

about extensively in the new book.

More out of lifePositive psychology developed

in the late 1990s. Previously, psy-chology had focused on alleviatingthe misery of people suffering frommental illnesses, she says.

“Many behavioral scientists arecoming to realize that traditionalpsychology concentrates on reduc-ing misery but does little to en-courage happiness. In other words,even when medications relievesymptoms of depression, the per-son may not be happy,” Manionadds.

Positive psychology recognizesthat people want more out of lifethan correcting their weaknessesand deficiencies. People want tolive lives of meaning and purpose,and they want to be happy, Man-ion asserts.

“Only focusing on what’s goingwrong leaves a staff demoralized.You may need to focus briefly onwhat’s gone wrong to make correc-tions, but if you don’t move pastthat, you’re going to stay stuckthere.”

As Martin E. Seligman noted inhis book, Authentic Happiness:Using the New Positive Psychology toRealize Your Potential for Lasting Ful-fillment, “the time has finally ar-rived for a science that seeks to un-derstand positive emotion, buildstrength and virtue, and provide

guideposts for finding what Aristo-tle called ‘the good life.’”

Joy at work?“Work and happiness? Joy at

work? For some, these terms seemcontradictory. Yet how a personfeels at work and whether he orshe is happy at work determine to

Learningevents with Jo Manion

Aug 19 Webinar: The Engaged Workplace:

Keeping Morale HighDuring Tough Times

Sign up atwww.ormanager.com

Managing Today’s OR Suite

All-day seminar:Appreciative Leadership:

Focus on What’s Going Right Breakout:

Live Your Legacy, and YourLegacy Will Live

Managing Today’s OR Suite Conference

Oct 7 to 9Caesars Palace,

Las Vegas

Download the conferencebrochure, and register

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“

“How can we use this challenge?

a great extent what that person’slife is like,” Manion writes.

Most people spend the majorityof their awake and alert hours atwork, and if they are not happythere, they often judge their lives tobe unhappy, she says.

Managers can have a lot to dowith the emotional environment ofa workplace, she adds. It has be-come conventional wisdom thatthe relationship between employ-ees and their manager is crucial toemployees’ commitment to staywith the organization, Manionsays. Research in positive psychol-ogy supports this assertion. Re-search from positive psychologyoffers concrete, evidence-basedsuggestions for establishing aworkplace in which happiness andjoy are key characteristics.

Energy producingThe number-one thing for OR

managers to know about positivepsychology techniques is that theyare energy producing, Manionsays. “If managers use the princi-ples of positive psychology—fo-cusing on strengths, having vision,developing feedback, and creatingrelationships—they’ll have moreenergy, and their staff will havemore energy,” she says.

She cites a couple of techniquesoutlined in The Engaged Workforce:an exercise called 3 Good Things(sidebar), and the practice of staffmembers doing acts of kindnessfor each other.

“For an OR, it would be power-ful if every staff member did 3 nicethings for others on the staff eachweek,” she said. “The ‘3 GoodThings’ exercise also is helpful tolift the mood of the workplace.”

Manion adds that Seligman hasstudied optimism extensively andreports it can be learned.

Positive for negativeManion includes specific steps

for managers to learn to substitutethe positive for the negative, bothbetween manager and staff andamong the staff.

“This is not ‘happiology’ but aresearched and tested approach tobetter management and a happier,more productive workplace,” shetold OR Manager. That includesproven strategies for handling staffwith subpar performance and be-havioral concerns.

“Influencing the performance ofothers is an important aspect ofcreating a positive work environ-ment,” she says. “Influencing andmanaging performance and prob-lem behavior are probably amongthe toughest challenges faced byorganizational leaders,” Manionconcedes. “Yet these are directlylinked to the quality of work lifefor people in the organization andmust be undertaken without fail.The pay-off is worth the effort.” �

—Kate McGraw

Kate McGraw is a freelance writer inSanta Fe, New Mexico.

ReferencesManion J. The Engaged Workforce:

Proven Strategies to Build a Posi-tive Health Care Workplace.Chicago: Health Forum, 2009.

Manion J. From Management to Lead-ership: Practical Strategies forHealth Care Leaders. 2nd ed. SanFrancisco: Jossey-Bass, 2005.

Seligman, M E P. Authentic Happi-

ness: Using the New Positive Psy-chology to Realize Your Potentialfor Lasting Fulfillment. New York:Free Press, 2002.

Seligman M E P. Learned Optimism:How to Change Your Mind. NewYork: Pocket, 1998.

Seligman, M E P, Steen T A, Park N,et al. Positive psychologyprogress: Empirical validation ofinterventions. Am Psychologist.2005.60(5):410-421.


Managing people

Continued from page 233 Good Things

Gratitude is an essential ele-ment in positive psychology, JoManion says. She has adapted forthe workplace gratitude exercisesproposed by positive psychologyleader Martin E. Seligman.

The exercises include a “grati-tude letter” and/or “gratitudevisit” to persons who have been ofbenefit in a person’s life.

Here’s how the exercise worksand how you can adapt it to yourworkplace.

Gratitude exercise • Before going to bed, write

down 3 good things, large orsmall, that went well that day.

• Next to each positive event,write an answer to this ques-tion: Why did this good thinghappen?

Even over a short time such as aweek, this activity has been foundto increase participants’ percep-tion of their happiness and reducedepressive symptoms for as longas 6 months, Seligman reports.

At work, Manion says man-agers have used the exercise at thebeginning or end of a shift, for in-stance, or at the beginning of awork week (“What 3 things wentwell last week?”) or when theyend meetings (“What is 1 goodthing you appreciate about thetime we have just spent to-gether?”).

“

“Substitute thepositive for the

negative.


Staying on top of code requirements

It is not enough to prevent infec-tion and always to identify theright surgery site. It is not enough

to have smooth hand-off proceduresand to question patients thoroughlyabout their allergies and ailments.To keep patients (and employeesand visitors) safe, the very architec-ture of an ambulatory surgery cen-ter (ASC) must conform to detailedstandards. Both state and federalstandards apply to surgery centers,and they extend far beyond suchcommon-sense rules such as notoverloading electrical circuits.

The Life Safety Code is complex,but meeting it is critical to compli-ance and accreditation. At the April2009 annual meeting of the ASC As-sociation in Nashville, Tennessee, fa-cilities planner William Lindeman,AIA, NCARB, reminded ASC man-agers of some basic considerations.

“There’s a real need for organiza-tions to understand what’s re-quired,” he told them.

The Life Safety CodeThe National Fire Protection As-

sociation (NFPA) issues the LifeSafety Code. In 2003, Medicare

adopted the 2000 version of NFPA101 for both new and existing ASCs.It addresses building design withthe goal of minimizing danger fromfire and its effects, including the abil-ity of occupants to escape. The codeis updated every 3 years, with thecurrent edition effective in 2009, andthe next update planned for 2011.

In addition, Lindeman noted,states have their own codes, whichmay be more restrictive than the na-tional one.

The Centers for Medicare andMedicaid Services (CMS) mandatescompliance with the code, which ingeneral covers facility configuration,size, construction, emergency equip-ment, and accessibility for disabledpersons. It is possible to obtain a

waiver in some circumstances, Lin-deman said, but the ASC mustdemonstrate there will be no loss ofpatient safety.

Compliance can be trickyMerely having a certificate of

compliance is not always enough,especially for older ASCs, he noted.Many regulatory officials and de-sign professionals, he said, are notaware of all of the requirements, andyet erroneous approvals are nevergrandfathered.

Even a fully compliant buildingcan go out of compliance because ofthe simplest of improvements or al-terations.

“Just adding a storage closet, animprovement, can bring a buildingout of code,” he said, because itcould affect space requirements oregress patterns. “There’s a lot ofthings a survey can uncover,” hesaid. For example, running a wirethrough a wall or connecting newequipment improperly couldchange compliance status.

His advice for anyone contem-plating a change is to first identify

Lee Anne Blackwell, RN, BSN, EMBA,CNORDirector, clinical resources and educa-tion, Surgical Care Affiliates,Birmingham, Alabama

Nancy Burden, RN, MS, CAPA, CPANDirector, Ambulatory Surgery, BayCareHealth System, Clearwater, Florida

Lisa Cooper, RN, BSN, BA, CNORExecutive director, El Camino SurgeryCenter, Mountain View, California

Rebecca Craig, RN, BA, CNOR, CASCCEO, Harmony Surgery Center, FortCollins, Colorado and MCR Surgery Cen-ter, Loveland, Colorado

Stephanie Ellis, RN, CPCEllis Medical Consulting, IncBrentwood, Tennessee

Rosemary Lambie, RN, MEd, CNORNurse administrator, SurgiCenter of Balti-more, Owings Mills, Maryland

LeeAnn PuckettMaterials manager, Evansville SurgeryCenter, Evansville, Indiana

Donna DeFazio Quinn, RN, BSN, MBA,CPAN, CAPADirector, Orthopaedic Surgery CenterConcord, New Hampshire

Ambulatory Surgery Advisory Board

“

“A survey can uncover a lot

of things.



those conditions that must be main-tained, which include anything re-lated to mechanical or electrical sys-tems or to safe exit patterns. Block-ing required exits or opening fire-walls for construction work, espe-cially above ceilings, would jeopar-dize compliance.

“Document everything related totesting and maintenance,” he advised.

Understanding building codes

Understanding definitions andterms for building elements in thesafety code is a big help in workingtoward compliance.

For example, minimum construc-tion requirements depend on thesize of the building. But how manystories does a particular ASC have?Lindeman noted that a space is not astory if more than 50% of the exte-rior wall surface is underground.Thus, an underground basement isnot a story. The exception, in somebut not all cases, is a walk-out base-ment.

The above-ground/below-groundrule is complicated by the fact thatbuildings often are constructed onsloped land. An apparent first floormay actually be more than 50% un-derground. Likewise, an attic not usedor occupied does not count as a story.

Identifying the stories is an im-portant first step in selecting theconstruction rules that apply. For ex-ample, if the building in which theASC is located, whether shared ornot, is found to be 1 story, it may beexempt from sprinkler require-ments. Otherwise, all floors in thebuilding must be protected by a su-pervised sprinkler system. “Super-vised” means monitored by an

emergency dispatching authority. Besides sprinklers, there is a sec-

ond option for protecting a multi-story building containing an ASC,and that is to have fire-rated con-struction throughout. Every struc-tural component, including columns,bearing walls, floors, and roof mustbe enclosed with material rated fire-resistive for at least 1 hour.

Meanwhile, an ASC occupyingonly 1 floor might be able to estab-lish “separate building” status bysurrounding itself completely with a2-hour firewall.

Getting outWell-publicized fire department

concerns about exits in any buildingtake on added detail when the struc-ture houses an ASC.

Any ASC of 2,500 square feet orlarger must have a minimum of 2

exits. “If it is even close,” he advised,“make sure the ASC area is thenumber being used, not the leasedarea, which usually includes com-mon areas outside the actual ASC.”The 2-exit minimum applies to anyfloor above ground level, in theform of separate stairwells.

The required exits must be sepa-rated by a distance equal to 1/2 ofthe facility’s maximum diagonal di-mension. The exception is if thebuilding has sprinklers, in whichcase the minimum distance is 1/3the building diagonal (illustration).

The exit system must includelighting on the entire exit pathway“from the most remote area to all re-quired exits,” Lindeman noted. Thatmeans backup power must be avail-able in the case of power loss, and itmust be adequate for safe naviga-tion for at least 90 minutes.

AmbulatorySurgery Centers


Minimum separation = 1/2 of maximum

dimension if building is not fullysprinklered

Minimum separation = 1/3 of maximum

dimension if building is fully sprinklered

Minimum dimension of suite or building

Example: Minimum separation ofrequired exits from a suite and/orbuilding.

Source: William Lindeman, AIA, NCARB.

Determining exit separation



Speaking of lights, Lindemannoted there are specific standardsfor exit signs. Directional signs mustbe posted leading to an exit, withthe exit sign itself located over thedoor. To indicate the direction of thenearest exit, an arrow will not do—athick, illuminated chevron mustshow the way.

Doors or windows that could bemistaken for escape routes but arenot must be labeled, “not an exit.”

Fire and smokeAn ASC of more than 5,000

square feet, or 10,000 square feetwith sprinklers, must be dividedinto at least 2 “smoke compart-ments” to prevent smoke fromspreading through the facility. To in-sure isolation, the walls must gothrough the ceiling to the upperfloor or roof and must extend from 1exterior wall to another. Connectionto other areas must be throughdoors rated for at least 45 minutes.

There must be similar protectionbetween the ASC itself and otherbuilding areas.

At each exit from the ASC, amanual fire alarm must be located.That doesn’t mean down the hall,but right at the exit, Lindeman ex-plained: “If there’s a fire, one of thetop priorities is to sound the alarm.”

Fire alarms must be tested regu-larly, and if inoperable for more than4 hours, the building must be evacu-ated, and the fire department noti-fied. Quarterly fire drills are recom-mended.

In addition to the alarms, ASCsmust have fire extinguishers promi-nently located and tested at leastonce a year. The facility must have afire emergency plan in place that in-cludes checking and maintainingexits to be sure they are not blocked,as with furniture or equipment.Hanging fabrics and decorations

must meet flame-retardant require-ments. Trash and soiled linen con-tainers must meet size and quantity-per-room limits.

Even hand sanitizer containersare hazards if they contain alcohol.Staff must control access to them,and they must be in range of sprin-klers. Corridors with wall-mountedsanitizer dispensers must be at least6 feet wide. Storing medical gases

Like other locations wheresurgery is performed, ASCs have abuilt-in hazard in the form of pipedmedical gases, and the safety codegives them special attention. A facil-ity has the choice, unless state regula-tions dictate otherwise, of installing acentral (or remote) source or portablecylinders. The operative regulationsare in the NFPA 1999 edition, whichrequires separate supports to holdup cylinder tanks.

Manifold rooms, where gas sup-plies or controls are stored, must belockable. Components of gas cylin-der storage rooms must be of non-combustible materials, includingwalls, floors, ceilings and supports.Doors must be metal. Electrical fix-tures and switches in these roomsmust be placed at least 60 inchesabove the floor.

Each cylinder must be individu-ally supported, usually by a chainattached to the wall. This standard issometimes ignored, Lindemannoted, displaying a photograph of aset of 4 cylinders connected by a sin-gle chain attached to a single wallsupport. Not legal, he said, becauseeach container must have its ownchain or be placed on a cylinderstand or cart.

The organization of stored gascylinders is also important, he


Life Safety CoderesourcesAccreditationAssociation forAmbulatory Health Care

AAAHC’s Physical Environ-ment Checklist for AmbulatorySurgical Centers (CD-ROM).

—www.aaahc.org

CMS State OperationsManual

Appendix L: Guidance to Sur-veyors: Ambulatory SurgicalServices.

—www.nfpa.orghttp://cms.hhs.gov/manuals/

Downloads/som107ap_l_ambulatory.pdf

Joint CommissionThe Life Safety Book: Guide to

Using the Joint Commission LifeSafety Chapter and Statement ofConditions.

—www.jcrinc.com/ProductDetails1620.aspx

National Fire ProtectionAssociation

NFPA 99: Standard for HealthCare Facilities.

NFPA 101: Life Safety Code—www.nfpa.org

“

“Quarterly fire drills are

recommended.



As if collecting payments fromMedicare, Medicaid, andprivate insurers wasn’t com-

plex enough, ambulatory surgerycenters (ASCs) face the added obsta-cle of being considered out-of-net-work by payers in many circum-stances. Out-of-network typicallymeans an ASC does not have a par-ticipation agreement with the payeror managed care organization or isotherwise not part of the panel ofparticipating providers.

The need for careful attention tocoding and documentation re-quirements is a given. But there arealso strategies for maximizing pay-ments and avoiding delays. For ex-ample, laws are strict about bal-ance billing of patients when pay-ers deny or reduce claims, and theyvary by state.

Know the lawASCs that know the laws and

communicate payment limits wellahead of time have the best chanceof recouping some or all of theircosts for providing care.

Michigan attorney AndrewWachler says he began to specializein ASC issues after successfullychallenging his state’s Blue CrossBlue Shield organization for deny-ing claims for surgery performedby physician-owned ASCs.

At the ASC Association confer-ence in May 2009 in Nashville, Ten-nessee, Wachler told ASC adminis-trators and staff there are no easy an-swers to questions such as, “Whencan I balance bill?” for unpaid claims.

“If you’re looking for black andwhite,” he said, “it’s very difficultto answer. These are state-by-statedeterminations.”

General guidelines Nevertheless, there are some

general rules. An ASC that pro-vides emergency service for a pa-tient in the Medicare Advantageplan will be paid in full, Wachlernoted. Commercial plans may re-sist paying if the ASC is out-of-net-work, but “there are ways you canchallenge them,” he said.

With changing federal regula-tions and 50 sets of state regula-tions, ASCs, especially those withmultiple facilities in differentstates, need to stay on their toes.However, he said there are trendsand principles they should beaware of.

Don’t neglect the ABNA provider must let the patient

know if it is likely that a procedurewill not be covered. For example,the treatment could be consideredcustodial care or not reasonableand necessary.

Effective March 1, 2009, theform for the advance beneficiarynotice (ABN) has been modified.Wachler noted that the rules statethat providers who do not providesuch notice that the services willnot be covered will be financiallyresponsible for the cost.

The exception is emergency

care, when the ABN should not begiven. The rules for ABNs can befound in the Medicare Claims Pro-cessing Manual, CMS-Pub. 100-04,Chapter 30, Section 50.

A delicate balanceWhen an ASC is considered an

out-of-network provider, reim-bursement may be reduced.Whether the ASC can then bill thepatient for the difference dependson both state law and the type ofinsurance.

While Medicare prohibits bal-ance billing of its beneficiaries,commercial insurers often allow itfor emergency care, depending onstate law. In Maryland and Florida,a provider may not balance bill forcovered services, but this can bemodified under private contractprovisions. In California, while bal-ance billing is also prohibited, pri-vate insurers must pay “the rea-sonable and customary value ofthe health care services rendered.”

No such restriction on balancebilling exists in Texas, where pay-ments are based on negotiatedagreements.

The copayment quandaryTo lessen the effect of higher

out-of-network copayments, ASCsmay offer to waive the extraamount. Such an offer places theASC on better competitive footing,Wachler noted. “But ask yourself,is it unfair inducement under statelaw?”

Not understanding state rulescan have serious consequences.Under the Health Insurance Porta-bility and Accountability Act

Recouping costs on out-of-network

“

“When can we balance

bill?


Don’t take a vacation from keeping up with the latest information on management of the OR.Summertime is a time for learning!Introducing the OR Manager webinar series.

With many health care facilities reducing educational funding and restricting travel, OR Manager is making our education programs more accessible through a new series of webinars on OR management.

Pour yourself some lemonade and brighten your summer with these outstanding presenters!

All sessions are an hour long and offered on Thursdays (unless otherwise noted) at 2:00 pm eastern time (1:00 pm central; 12 noon mountain; 11:00 am Pacific).

Learn and earn 1 CEU for each session.

Christy Dempsey, RN, MBA, CNORAugust 6 Assessing and Developing of a Patient Flow

Improvement ProjectAugust 13 Implementing a Successful Patient Flow

Improvement Project

Jo Manion, RN, PhD, NEA-BC, FAANAugust 19 The Engaged Workforce: Keeping Morale

High During Tough Times (Wednesday)

Keith Siddel, MBASeptember 17 Improving the OR Revenue CycleOctober 1 Taming the Charge Description Master

William J. Mazzei, MDSeptember 10 The Perils and Pitfalls of Block Scheduling

The webinarseries for new

managers will beginon October 22 andcontinue through

December

Get more information andregister at www.ormanager.com



noted. They must be placed so thatthe cylinders can be used in theorder in which they are receivedfrom the supplier. Empty cylindersmust be segregated and marked toavoid being mistaken for full ones,because confusion could cause adelay in furnishing gas and threatenpatient safety. No other equipmentshould be stored in cylinder rooms.

What happens if the power fails?

While changing light bulbs andchecking electrical outlets for safeoperation are indeed important tostaying in compliance, the code alsoaddresses emergency power, a criti-cal factor in any medical facility.

Electrical system requirements arebased on whether a facility uses onlylocal anesthesia or if it ever uses gen-eral anesthesia.

The first may use a “type 3” sys-tem, “typically battery-based andfairly simple to achieve,” accordingto Lindeman. However, if the ASCeven contemplates using generalanesthesia, it must install a “type 1”system identical to that used in hos-pitals.

A type 1 system is designed toprovide continuous operation on 2levels: first, the building functionssuch as air conditioning, and second,the “critical” functions such as run-ning ventilators, which will keep apatient alive. The 2 systems musthave separate branch wiring and cir-cuit protection.

“So be careful,” he advised. “Ifyou want to go from local to generalanesthesia procedures, you usuallyhave to rewire the entire ASC.”

Test and maintainOnce in place, the system must be

regularly tested and maintained. Forexample, check emergency batteriesfor corrosion on the terminals, he ad-vised. If the backup is a generator, itshould be run monthly, or 12 timesper year.

“Atest I like to do,” he said, “is to killthe power in the whole building on aweekend when there are no patients.”

Because it is so easy to fall out ofcompliance when making changesor in the course of normal operations(such as moving equipment thatcould block an exit), Lindeman ad-vised fully documenting every ac-tion related to testing and mainte-nance, especially in these areas:• piped medical gas systems• emergency power• egress and exit sign lighting• fire sprinklers• smoke and fire alarms.

In addition, ASCs should keeptrack of all mechanical and electricalcomponents that need to be main-tained. Even redecorating can affectcompliance; for example, there arestandards for carpet height where itintersects with bare floor, as it couldbecome a tripping hazard.

For further guidance, ASCsshould consult their state health de-partments “to help establish yourconformance baseline,” Lindemansaid. There are handbooks explain-ing the NFPA rules, but at least keepon hand the 2000 editions of NFPA101 and the 1999 edition of NFPA 99.The Centers for Medicare and Med-icaid Services (CMS) publishes theCMS State Operations Manual, andASCs can also consult with theirdeemed status accrediting body forstandards and checklists. �

—Paula DeJohn

Life Safety CodeContinued from page 27

(HIPAA), a “false claims” provi-sion could be interpreted to im-pose potential criminal penaltiesfor seeking reimbursement forcharges that reflect a copay thatwas not collected, even for privateinsurance claims.

“A pattern of waiving copays,”Wachler explained, “could be inter-preted to mean you are claiming tocharge more than you really are.For example, let’s assume youcharge $100 and the insurancecompany pays 80%, then the pa-tient owes a 20% copay. If youwaive that, the insurance companymay claim it only owes 80% of the$80 you are actually charging.”

That would reduce the insurer’sliability to 64% of the total cost.

In a Michigan case that Wachler ar-gued, the insurance company termedthe copay waiver a “kickback.”

“I think the key issue in all ofthese cases is whether you’re mak-ing a false statement; ie, not mak-ing a full disclosure,” he said.

To avoid exposure, one solutionis to notify insurers of the ASC’sbilling practices, such as discount-ing or waiving a patient’s share.“However,” he added, “such noti-fication will often not be favorablyreceived by the insurers, who maythen ask you to cease and desistsuch practices.”

Under Medicare, it is not per-missible to waive a copay unlessthe provider can demonstrate itwould be a hardship to the patient.“There is very little leeway,” Wach-ler said. �

—Paula DeJohn

ASC billingContinued from page 28


P O Box 5303Santa Fe, NM 87502-5303


The monthly publication for OR decision makers Periodicals

At a Glance

Higher complications,costs with BMP in anteriorcervical fusions

Use of bone-morphogenetic pro-tein (BMP) in anterior cervicalspinal fusions is linked with ahigher rate of complications andgreater hospital charges, finds astudy in the July 1 JAMA.

Complications occurred in 7%of patients with BMP vs 4.7% with-out. No differences were seen forlumbar, thoracic, or posterior cervi-cal fusions. Total hospital chargeswere 11% to 41% higher with BMPuse for all categories of fusion.

BMP use has increased from0.69% of all fusions in 2002 to al-most 25% in 2006. In July 2008, theFDA issued an alert on life-threat-ening complications following useof BMP in cervical spinal fusions.

—Cahill K S, Chi J H, Day A, et al.JAMA. 2009;302:58-66.

Study: Tubular diskectomyno better thanmicrodiskectomy

Sciatica patients have no betteroutcomes with tubular diskectomythan with the conventional mi-crodiskectomy, finds a study in theJuly 8 JAMA.

The rationale for the less-inva-sive transmuscular tubular diskec-tomy, introduced in 1997, was thatless tissue damage from splittingrather than slicing muscles wouldresult in faster recovery with simi-lar long-term outcomes.

But the study found functionalstatus was no better with tubulardiskectomy than microdiskectomyat 8 weeks or 1 year postop. Differ-ences in pain intensity and recov-ery rates also favored microdiskec-tomy.—Arts M P, Brand R, Van den Akker

E, et al. JAMA. 2009;302:149-158.

Total knee surgeryappears cost-effective inMedicare patients

Total knee replacement appearscost-effective for Medicare-agedpatients with advanced os-teoarthritis, finds a study in theJune 22 Archives of Internal Medi-cine.

Patients having knee replace-ment had about 1 year of betterquality of life compared to patientswithout the procedure. The year ofbenefit cost about $18,300, withinthe range of accepted cost-effec-tiveness.

The procedure appeared morecostly and less effective in low-vol-ume than in high-volume centers.

—Losina E, Walensky R P, KesslerC L, et al. Arch Intern Med.

2009;169:1113-1121.

Surgery among 100priorities for effectivenessresearch

The Institute of Medicine (IOM)on June 20 recommended 100 pri-orities for a new national researcheffort to identify the most effectivetreatments. The IOM developedthe priority list as part of Congress’$1.1 billion effort to improve healthcare through comparative effec-tiveness research.

Surgical topics on the list arestrategies for reducing surgical siteinfections, effectiveness of roboti-cally assisted surgery, treatmentsfor cervical disc and neck pain, ef-fectiveness of virtual colonoscopy,treatment for obesity, and effective-ness of anticoagulant therapies fortotal joint replacements. �

—www.iom.edu/Object.File/Mas-ter/71/032/Stand%20Alone%20List%

20of%20100%20CER%20Priori-ties%20-%20for%20web.pdf

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