Identifying surgical sites; Medicare reimbursement; artificial fingernails; acronyms; salespeople in the OR

AORN Journal, March, 1999 by Dorothy M. Fogg

Question: In our facility, we have no specific protocol for identifying the correct surgical site. We are In the process of preparing for our Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey and I have heard that the JCAHO is interested in seeing such a policy In facilities that perform surgery. Should we have a policy, and, if so, what should it include?

Answer: Although AORN has not addressed this question to date, it certainly seems prudent for the facility to have a policy and procedure in place and to see that all people involved in patients' surgical care follow that policy and procedure. Any surgery that is performed on the wrong site is a serious concern. The consequences for the patient and for the facility and its practitioners can be devastating. It is human nature to think that wrongsite surgery could never occur, but in two years' time, the JCAHO's accreditation committee reviewed 15 cases of wrong-site surgery. Others may have occurred but were not reported. The majority of reported wrong-site surgeries were orthopedic procedures, with urologic and neurosurgical procedures also contributing to the total number of 15.(1)

The JCAHO's reviewers identified several factors that may contribute to an increased risk of wrong-site surgery. These include

* having more than one surgeon involved in the procedure;

* performing multiple procedures on the patient during a single surgical encounter, especially when different procedures are performed on different sides of the patient;

* time pressures due to unusual start times;

* pressure to decrease preoperative preparation time;

* patient characteristics requiring unusual equipment setup or patient positioning on the surgical bed;

* failure to include the patient and/or family members when identifying the correct site;

* incomplete or inaccurate communication among members of the surgical team; and

* incomplete preoperative assessment of the patient(2)

Having identified possible contributing factors leading to wrong-site surgery, the JCAHO suggests the following strategies for reducing the risk of this serious error.

* Clearly mark the surgical site.

* Involve the patient in the process of identifying the correct site to improve reliability.

* Require an oral verification of the correct site in the OR by each member of the surgical team.

* Develop a verification checklist that includes all documents referencing the intended surgical procedure and site (eg, history and physical, surgical permit, x-rays or other image studies, surgery schedule).(3)

By including such things in your policy, you will be creating a system of checks and balances that can contribute to safe practice.

Question: I am the director of a new ambulatory surgery center (ASC), and my physician-owners want to be reimbursed far the Medicare patients we serve. This was never mentioned until recently. I was given carte blanche in terms of obtaining accreditation, and the physicians have Indicated no preference in this matter until now. Most of my energy has been focused toward obtaining accreditation by one of the national accrediting agencies specifically for ambulatory surgery facilities, such as the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF). It is my understanding that our facility will have to be certified by a state survey agency for us to receive Medicare reimbursement. Does this mean we will need to prepare for two surveys if we want the AAAASF accreditation?

Answer: As of Dec 2, 1998, a facility such as yours needs to prepare for only one survey to obtain both Medicare and AAAASF certification. As of the December date, the Health Care Financing Administration (HCFA) approved "deemed" status for the AAAASF. This means that ambulatory surgery centers meeting the certification requirements for AAASF are deemed to have met the Medicare participation requirements. An additional state survey is no longer necessary. To participate in the Medicare program, ambulatory surgery centers must meet conditions for participation that are specified in HCFA regulations. In the past, ASCs entered into a Medicare participation agreement, but only after being certified by a state certifying agency as complying with the conditions for participation set forth by HCFA. These state agencies then conducted interval surveys to determine that the facility continued to be in compliance with the conditions for participation. Any facility found not in compliance risked having its participation in the Medicare program terminated.(4)

Ambulatory surgery centers achieving accreditation by a national accrediting body with deemed status are exempt from state agency surveys. Instead, the accredited facility is surveyed according to the certification/ recertification protocol of the certifying body. In addition to the AAAASF, both the JCAHO and the Accreditation Association for Ambulatory Health Care have been given deemed status by HCFA. All three of these accrediting bodies have a three-year resurvey cycle. Keep in mind, however, that all AAAASF surveys are unannounced, and facilities are asked to submit staffing schedules to AAAASF on a regular basis after completing an accreditation application. This is done so the AAAASF unannounced survey can be conducted when key staff members are available.