Surgery centers: Are you ready to provide written care plans?
Surgery centers: Are you ready to provide written care plans?
Medicare conditions of participation would be a burden, managers warn
A preliminary draft of changes to Medicare conditions of participation for ambulatory surgery centers (ASCs) would require written care plans and other burdensome requirements, according to several ASC managers.
"I think HCFA [Health Care Financing Administration] has lost sight of the fact that Medicare patients, according to [HCFA’s] own rules, can spend a maximum of 51¼2 hours in an ASC setting, and the majority of Medicare patients probably spend less than three," says Steven Gunderson, DO, medical director/administrator of Rockford (IL) Ambulatory Surgery Center.
Because of the high volume of patients and the short time they are in the facility, the requirement for a written care plan would be an administrative burden on surgery centers, Gunderson and others say. According to the draft, each patient would have to have a written plan of care that includes a doctor’s recommendation for admission to the ASC and meets the patient’s needs identified in a comprehensive assessment. That assessment would evaluate the patient’s condition and care needs at the time of admission before surgery. The plan would include a pre- and post-evaluation performed by qualified anesthesia staff and would include an initial assessment of the patient’s post-surgical needs. It would have to be modified to meet any changes in the patient’s condition that affect the patient’s needs.
"Written care plans are probably unnecessary to the provision of care and would add unnecessary paperwork," agrees Nancy Webb Kessler, BSN, MS, executive director of El Camino Surgery Center in Mountain View, CA.
This paperwork adds to the ASC costs, Gunderson points out, but there’s no provision for passing along such costs to patients. "It does little to level the playing field, which HCFA has said from the beginning they were trying to do," he says. (For reports of HCFA’s overall plans for surgery center reimbursement, see Same-Day Surgery, December 1996, p. 133.)
Kessler suggests, "Better results could be achieved by having standards of care clearly stated and only exceptions recorded. Significant exceptions should be reviewed and acted on in the QI process."
7 more changes that could be a burden
The following draft requirements also would be a burden for ASCs, according to Bergein F. Overholt, MD, president of the Chicago-based American Association of Ambulatory Surgery Centers, formerly the American Society of Outpatient Surgeons:
• The ASC is not a part of any other provider and is separate and distinct in terms of licensure, accreditation, governance, professional supervision, administrative functions, clinical services, record keeping, and financial and accounting systems.
"We feel that is not in the best interest of patient care," Overholt says. Many ASCs, for example, are located next to a physician’s office and may be jointly incorporated. The proposal would eliminate any such relationship, he says.
"To my understanding, there is currently no requirement that an ASC be a distinct legal entity from any other provider, and the proposed regulation just makes things more difficult and does not accomplish any improvement in outcomes," he says.
• The ASC must have a recovery room and waiting area that are separate from any other facility.
In situations in which a physician’s office and surgery center are joined, "We strongly believe that common waiting room serves the interest of not only the patients, but the cost- efficient provision of medical care as long as patient rights are protected" in terms of privacy, Overholt says.
For single-specialty same-day surgery programs, such as gastroenterology and urology, there’s no reason for a separate waiting area, he maintains.
• Clinical records must be retained in a reproducible form for at least five years.
"The five-year requirement should be only for those records appropriate for the procedure," Overholt suggests. For example, with an arthroscopy, the X-ray obtained in the center before surgery should be kept. "But if it’s an outside X-ray, that should not be a requirement," he says.
• The ASC must maintain an operating room register that should not only list the scheduled surgical procedures, but also include the CPT-4 code.
"It would be an unnecessary burden for ASC staff to have to list things by CPT codes," Overholt says. "They’re totally unfamiliar with that system now, and [the draft requirement] doesn’t serve any interest in terms of improving patient care."
• The ASC’s patient medical record should include significant medical history and results of the comprehensive assessment.
"It simply is unnecessary for ASCs to retain significant medical patient histories, but instead it should be the history relevant to the procedure performed," Overholt maintains.
For example, with an arthroscopy, the relevant history is related to the joint symptoms and any major illnesses, such as heart disease. "But it’s probably not relevant to have a history that includes urinary and pulmonary and other systems, particularly if they’re normal," he says.
• The ASC’s patient medical record should include an operative report describing the length of time used in performing the surgical procedure(s).
The length of time already is documented in the ASC records, Overholt points out. "And second, if a surgeon dictates the operative report right after the procedure, how is that surgeon going to know the preoperative time, the intraoperative time, and the postoperative time for anesthesiologists?" he asks. It’s an impractical requirement, he maintains.
• A registered nurse must be immediately available for emergency treatment whenever a patient is in the ASC.
"We are suggesting that an RN or a physician must be immediately available," Overholt says.
HCFA asked to clarify questionable areas
These areas of the draft regulations need clarification, same-day surgery managers suggest:
• The ASC must conduct a comprehensive assessment of the care needs of each patient, including an initial assessment of post-surgical needs.
"The facility can’t be responsible for the medical assessment," Kessler says. "The physician has to be responsible."
• The physical environment prevents situations that pose a threat to health or safety whenever possible; when they do occur, they must be reported and corrected. The physical environment prevents equipment failures whenever possible; when they do occur, they must be reported and corrected promptly.
"We believe HCFA is not intending to require ASCs to report all events to state health departments or agencies, but should develop policies within their own ASC to report to their board of directors any adverse events," Overholt says.
• Administrative responsibilities include notifying the state survey agency when the ASC adds new service categories and notifying HCFA and the state agency when there is a change in ownership.
"What does a new service’ mean?" Overholt asks. "It could be a minor procedure, and you have to notify the state, and they have to do state review. We want further clarification on that."
Despite their concerns, same-day surgery managers agree that the draft regulations on conditions of participation are on the right track, and Overholt describes the proposed changes as "bold."
Same-day surgery managers are particularly glad to see the quality assessment (QA) and performance improvement (PI) requirements spelled out. Under the draft proposal, the QA requirements have been expanded with a focus on outcomes measurement.
The ASC must implement a data-driven QA and PI program. Standards address QA, measurement of quality indicators or performance, and program responsibility by the governing body, medical staff, and administrative officials.
"They are designed to move in the direction of a patient-oriented, outcome-data-driven system," Overholt says.
Gunderson also lauds the move toward a patient- and outcomes-oriented system.
"The entire industry is driven by QA and outcomes management at the present time," he says. "I feel any ASC managed by knowledgeable health care administrators is constantly trying to improve patient care and outcomes. HCFA is now requiring a paper trail to prove the ASC is indeed doing that."
HCFA’s next scheduled change in ASC reimbursement involves additions and deletions to the Medicare list of ASC-approved procedures, which an agency representative said at Same-Day Surgery press time it expects to publish before summer. The proposed conditions of participation should be published after that, according to the agency.
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