QOTW – QUESTION OF THE WEEK: ASC’s Governing Body and ASC Policies

What is the CMS regulation that addresses the responsibilities of an ASC’s Governing Body and the ASC’s policies and procedures?

CMS (§416.41) requires Ambulatory Surgical Centers (ASC) to have a governing body that assumes full legal responsibility for determining, implementing, and monitoring policies governing the ASC’s total operation.  The governing body is responsible for establishing the ASC’s policies, making sure that the policies are implemented, and monitoring internal compliance with the ASC’s policies as well as assessing those policies periodically to determine whether they need revised.

The governing body has oversight and accountability for the quality assessment and performance improvement program, ensures that the facility policies and programs are administered so as to provide quality healthcare in a safe environment, and develops and maintains a disaster preparedness plan.

The regulation particularly stresses the responsibility of the governing body for:

  • Direct oversight of the ASC’s quality assessment and performance improvement (QAPI) program
  • The quality of the ASC’s healthcare services
  • The safety of the ASC’s environment; and
  • Development and maintenance of a disaster preparedness plan

In the case of an ASC that has one owner, that individual constitutes the governing body.

Delegations of governing body authority should be documented in writing.

Related Products from MCN:
Ambulatory Surgical Center and Outpatient Surgery Department Policy and Procedure Manual

Policy Manager Automated Workflow Software

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Joint Commission Releases Sentinel Event Statistics – 2004 through 2013

The Joint Commission (TJC) has released a Summary of Sentinel Events for 2004 through 2013.  Sentinel Events are defined by TJC as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”  These events are called “sentinel” because they signal a need for immediate investigation and response.

The reporting of most Sentinel Events to The Joint Commission is voluntary and therefore TJC believes the numbers represent only a small proportion of actual events.  The report includes the following data:

  • Type of Sentinel Event
  • Settings of Sentinel Events
  • Sources for Sentinel Events Identification
  • Sentinel Event Outcomes
  • Self-reported Sentinel Events by Year
  • Method for Review of HCO Response to Sentinel Event

From 2004 through 2013 the most often reported Sentinel Events were:

  • Wrong–patient, wrong‐site, wrong‐procedure
  • Delay In Treatment
  • Unintended Retention of a Foreign Body
  • Op/Post‐op Complication

During the time period of 2004 – 2013, 66% of Sentinel Events reported occurred in hospitals; 59% of Sentinel Event outcomes resulted in patient death.

This data reinforces the need for health care organizations to focus on preventing Sentinel Events.

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MCN Learning: Nurse Fatigue

Anyone who is a nurse has either experienced, read about, or knows someone who has burnout. The official definition of burnout is “an emotional condition marked by tiredness, loss of interest, or frustration that interferes with job performance. Burnout is usually regarded as the result of prolonged stress.”

After analyzing several articles written about burnout, specific causes of this affliction in nursing were identified which include:

  • Stressful, even dangerous, work environments
  • Lack of support
  • Lack of respectful relationships within the health care team
  • Low pay scales compared with physicians’ salaries
  • Shift changes and long work hours
  • Understaffing of hospitals
  • Pressure from the responsibility of providing continuous high levels of care over long periods
  • Frustration and disillusionment resulting from the difference between job realities and job expectations

Over the last few weeks several nursing list servers have been particularly active with discussions about burnout and nurse fatigue. One nurse in particular believes that burnout is an overused term and because of that it is not getting the attention it deserves. As this nurse elaborated, nurses who are demonstrating or experiencing burnout are counseled to either take a vacation or find another job.

I believe the phrase nurse fatigue might be more applicable to define nurses who are getting “tired” of the same issues, expectations, and conversations that get them absolutely nowhere. When reviewing and participating in Facebook entries and list server comments, the majority of nurses are not commenting on “dangerous work environments” or even “pay inequity with other healthcare professions.” The comments focus on the apparent disregard by senior leadership to even notice or recognize the role of nurses in healthcare.

Another nurse provided interesting information for those of us participating in the conversation. This nurse found data to support that the best places to be a nurse is along the West Coast, specifically California, Hawaii, Oregon, and Nevada. If anyone lives on the East Coast, the best places to be a nurse are in Massachusetts, New Jersey, Maryland, Connecticut, and Delaware. After taking a quick poll on those of us participating in the discussion, we learned that none of us were licensed to practice nursing in these states.

As one participant pointed out, since the chance that nurses were going to relocate to one of these “ideal” states for nursing was slim to none, there needs to be another way or approach to take when episodes of “fatigue” set in. The participants jumped on this suggestion and generated a huge list of things that nurses can do when “fatigue” sets in. A few of these suggestions were:

Take a day off to do something only for the nurse such as get a haircut, go to lunch, shop, or spend time with non-nurses

  • Find sunlight, somewhere
  • Do something physically fun such as ride a bike, take a walk, play tennis, bounce a ball, or bowl
  • Plan a day of special meals that are nutritionally sound and vitamin-packed

One astute participant realized that the group was generating a to-do list of things to improve the nurse and not necessary the situation. As the light-bulbs were going off and the participants were experiencing an “ah-ha” moment, the tone of the conversation changed dramatically.

Yes, nurses are notoriously overworked, underpaid, and underappreciated. However, we do not have to accept that as our plight. Each nurse possesses infinite power to change the most important person – themselves. So as each participant was slowly signing off those who remained commented that although the conversation started out as a major griping session it quickly turned around to being one of the most productive.

Spending time with other nurses has both advantages and disadvantages. The disadvantages are obvious since most nurses will feed off of each other’s negativity however at times, a positive approach can change the entire focus and outcome. One can only hope that other nurses will find the positive in an otherwise repetitively negative situation. Until that occurs, embrace the day!

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