OUTPATIENT OPHTHALMIC SURGERY SOCIETY

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OUTPATIENT OPHTHALMIC SURGERY SOCIETY

• NATIONAL SYMPOSIUM
• OCTOBER 5 6, 2007
• Connie Belden R.N., BSHSA, NCIT
• Team Leader, Office of Medical Facility
  Licensing
• Arizona Department of Health Services

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• THE ROAD TO MEDICARE CERTIFICATION, STATE
  LICENSURE AND ACCREDITATION

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(No Transcript)
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STATE LICENSINGPROCESS
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CERTIFICATION PROCESS
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MEDICARE CERTIFICATION

• Medicare contracts with State Agencies
• 1864 Agreement
• Formal agreement between the Secretary of Health
  and Human Services individual states to carry
  out specific survey and certification provisions
  of the Social Security act
• State agency agreement delineates
• Accountability
• Responsibility for Medicare Certification
• Each surgical center
• Surveyed for Medicare certification
• State Agency
• Accreditation Organization

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PROCESS FOR MEDICARE CERTIFICATION by STATE AGENCY

• CMS depends on the State Agencies to set the
  standards for initial licensing
• Conditions for Coverage (COCs) are considered the
  minimum acceptable standard for performance in
  order for a facility to be reimbursed for
  services by Medicare

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PROCESS FOR MEDICARE CERTIFICATION by STATE AGENCY

• Medicare Expectations
• Governing Board and the Facility Personnel are
  aware of and implement requirements of the State
  Agency and Medicare COCs
• Must know and understand all state rules related
  to the surgical center
• Must know and understand all COCs for Ambulatory
  Surgery Center
• For facilities that are accredited
• Compliance with the Conditions for Coverage
  expected
• Complaint investigations
• Accreditation Validation Surveys
• Facility is at all times in compliance with
• Federal Conditions for Coverage and State
  rules/regulations
• The highest rule/regulation
• State Agency
• Medicare COCs
• Facility Policies and Procedures

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PROCESS FOR MEDICARE CERTIFICATION by STATE AGENCY

• All surveys are conducted as unannounced surveys
• Recertification surveys have generally been every
  3-4 years
• Based on the Mission and Priority
• Developed with each Budget year
• Priority
• Survey cycle
• Exceptions
• Validations Surveys
• Complaint Validations/Investigations
• At Risk Facilities
• Survey is to determine substantial compliance
  with the COCs

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PROCESS FOR MEDICARE CERTIFICATION by STATE AGENCY

• Facility Responsibility during a Survey
• Respond to surveyor questions
• Provide all requested documentation
• Ensure all of your questions are asked and
  answered
• Provide supporting documentation and information
  when questions are raised related to compliance
• Always be honest with the surveyor or survey team

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PROCESS FOR MEDICARE CERTIFICATION by STATE AGENCY

• Survey Team Responsibility during Survey
• Utilize the process defined in the State
  Operations Manual established by CMS
• Entrance Conference
• Compliance Review Activity
• Document Review
• On-Site Department Tours
• On-Site Interviews
• STAFF
• MANAGEMENT
• PHYSICIANS
• PATIENTS/FAMILIES
• ON SITE RECORD REVIEWS
• Concurrent
• Retrospective
• Observation of Care and Services Provided
• Survey Direction Based on Outcomes Identified
  During the Survey Process
• Exit Conference - Courtesy

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PROCESS FOR MEDICARE CERTIFICATION by STATE AGENCY

• Deficiencies Identified
• How do I process?
• Make sure you understand the deficient practice
  that is documented
• Utilize your resources to determine an
  appropriate plan of correction that demonstrates
  action and continued compliance
• State Agency
• Regional Office
• Local Resources
• Peers/Personnel within the facility
• Literature Review for Best Practices
• Consultation
• Professional Organization
• Private Sector Consultants

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I have always done it this way and no one has
identified it as a deficient practice before.

• Deficient Practice may be identified for various
  reasons
• New regulation
• New interpretation and/or clearer understanding
  of the regulation
• Survey process focuses on substantial compliance
  and previous surveys may not have identified the
  deficient practice as a non-substantial
  compliance area
• In the end you must determine how you will be in
  compliance

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PROCESS FOR MEDICARE CERTIFICATION by STATE AGENCY

• Completing a Plan of Correction
• Address each deficient practice
• Clear and Concise documentation of
• Action taken or to be taken with timeline of
  completion
• Usually within 30 days
• Responsible party must be identified
• How the facility will monitor action plan to
  ensure ongoing compliance
• Plan of Correction Review
• May require on-site survey for validation of
  compliance
• May require a full Condition for Coverage Survey
  if deficient practice is at Condition Level
• May be reviewed and accepted without an on-site
  survey

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• AMBULATORY SURGERY CENTER
• BASED ON
• CMS SURVEY ACTIVITY

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AMBULATORY SURGERY CENTER UPDATE ON CMS ACTIVITY

• Survey Outcomes
• Increased number of Conditions for Coverage not
  being met
• Increased Enforcement
• More Ambulatory Surgery Centers being terminated
• A terminated facility may be denied readmission
  via accreditation

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AMBULATORY SURGERY CENTER UPDATE ON CMS ACTIVITY
(cont.)

• Quality of Care Concerns
• Lack of nursing staff
• No nurse in the operating room
• No RN available for emergencies
• Patient assessment problems
• Major infection control issues
• Medication administration and storage concerns
• No governing body or an inactive governing body
• No oversight or proctoring of surgeons
• Medical record documentation lacking
• Incomplete surgical logs
• Patient privacy problems

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What can I do to be Pro-Active?

• Know your key contacts
• Consultants
• Peers
• Accreditation Organizations
• State Agency
• Develop relationships with organizations
• Share Best Practices
• Become involved directly or indirectly with rule
  making
• Keep current with the regulations visit the web
  sites frequently
• Have open relationships with your State Agency
• Ask Questions Dont Wait and See

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RESOURCES

• Web sites
• www.cms.hhs.gov
• www.cms.hhs.gov/CFCsAndCoPs/ASC.
• www.cms.hhs.gov/GuidanceforLawsAndRegulations
• Ambulatory Surgery Regulations 416.2 through
  416.49
• Regulation
• Interpretative Guidelines
• Survey Procedures
• State Operations Manual
• State Agency Procedures
• Survey and Certification Letters
• Updates
• Regulation
• Interpretive Guidelines
• Survey Process
• State Agency
• Licensing Rules/Regulations

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SUMMARY

• Understand and meet all State Licensing
  rules/regulations
• Remember CMS Conditions for Coverage are the
  baseline requirement for certification --
  Facility must be continually in compliance even
  when certified through an accrediting agency
• Ongoing readiness is key to success - CMS surveys
  are unannounced
• Actively participate in the survey process
• Utilize your best resources to develop a plan of
  correction
• Do your own self-surveys, being objective about
  the practice within your facility
• Integrate compliance with your Quality
  Improvement Program
• Develop collaborative relationships with other
  facilities
• Involve your internal personnel

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REGULATION

• Regulations are the baseline requirements to the
  performance journey of excellence in the
  outpatient surgical setting.

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A Proactive Approach to the Survey Process

• Beth Hurley, RN, BSN, CRNO, COE
• Ophthalmic Surgery Resources, Inc.

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Know your state rules

• Where to find State regulations
• Some states are easy check out Texas
• www.dshs.state.tx.us/HFP/asc.shtm
• Dont know who to contact
• www.cms.hhs.gov/SurveyCertificationGenInfo/Downloa
  ds/State_Agency_Contacts.pdf

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Know what they want CMS

• CMS Conditions for coverage and standards
• www.cms.hhs.gov/manuals/downloads/som107ap_l_ambul
  atory.pdf
• State Operations Manual
• Appendix L Guidance to Surveyors
• Ambulatory Surgical Services

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Want to know more

• CMS web page dedicated to ASC information
• Approved codes and payment rates
• Billing and coding
• Enrollment and participation
• Educational resources/Contacts/How to stay
  informed
• Federal register notices
• www.cms.hhs.gov/center/asc.asp

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Have a say

• Spotlights
• CMS-3887-P - Ambulatory Surgical Centers,
  Conditions for Coverage (Comments due no later
  than 500pm on October 30, 2007)
• Updated Ambulatory Surgical Center Payment
  Information for Value-Driven Health Care (posted
  August 29, 2007)
• CMS-1517-F - Revised Payment System Policies for
  Services Furnished in Ambulatory Surgical Centers
  (ASCs) Beginning in CY 2008, on display in the
  Federal Register July 16, 2007
• CMS-1392-P - Proposed Changes to the Hospital
  Outpatient Prospective Payment System and CY 2008
  Payment Rates Proposed Changes to the Ambulatory
  Surgical Center Payment System and CY 2008
  Payment Rates (Comments due no later than 500pm
  on September 14, 2007)

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Participate

• Belong to a professional organization
• Outpatient Ophthalmic Surgical Society
• www.ooss.org
• American Association of Ambulatory Surgery
  Centers
• www.aaasc.org
• FASA
• www.fasa.org

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Become accredited

• Accreditation Association for Ambulatory Health
  Care (AAAHC)
• www.aaahc.org
• American Association for Accreditation of
  Ambulatory Surgical Facilities
• www.aaaasf.org
• The Joint Commission for the Accreditation of
  Healthcare Organizations (JCAHO)
• www.jointcommission.org
• The following states recognizing accreditation
  for ASC
• Arizona, Arkansas, Florida, Georgia, Nebraska,
  Nevada, Ohio, Rhode Island,
• Texas, Wyoming

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Educate yourself

• American Society of Ophthalmic Registered Nurses
• www.asorn.org
• AORN
• www.aorn.org/Education/ProfessionalDevelopment
• Check out the Ambulatory Surgery Administrator
  Certificate Program (they also have an Advanced
  Program and Peri-op 101)
• CASACertified Administrator Surgery Center
• www.aboutcasc.org

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Know when to seek help!

• If your facility has more than (4) deficiencies
• If your facility fails a follow up survey
• If you cant find your Policy and Procedure
  Manual, Quality Assurance Program or Medical
  Staff credentialing files
• If no one in the facility realized that there are
  rules and regulations!

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Contact information

• Beth Hurley, RN, BSN, CRNO, COE
• Ophthalmic Surgery Resources, Inc.
• [phone]
• hurleybeth_at_aol.com

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SURVEYING THE SURVEYOR

• Barbara Ann Harmer
• MedAssist Consultants, Inc.

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SURVEYING THE SURVEYOR

• Who is the AAAHC surveyor?
• What training does a surveyor have that
• gives he/she the right to judge me?
• What should I expect from my surveyor?

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SURVEYING THE SURVEYOR

• Are you my friend?
• Should I be frightened by you?
• Should I be intimidated by you?

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SURVEYING THE SURVEYOR

• Food
• Water
• Sun

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SURVEYING THE SURVEYOR

• Key AAAHC Standards
• Governance
• Administration
• Clinical Records Health Information
• Quality Management Improvement

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Contact Information

• MedAssist Consultants, Inc.
• Barbara Ann Harmer
• Telephone [phone]
• E-mail ConsultMACInc_at_aol.com

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OOSS ASC Benchmarking Pilot Survey - 2007
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• Introduction

• Background
• Benefits
• OOSS Brand
• Opportunities
• Consultants
• Participants

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• Data Interpretation and Reporting
• Comparative Report - In Progress for Pilot Study
  
• Release in Detail with Recommendations for
  Refinements to Participants and Board - November,
  2007
• Summarized on OOSS Website for Public Viewing -
  December, 2007

• Users Guide
• Simple explanations of how to compare results
• Results displayed with individual ASC responses,
  like size responses and all responses
• Identification of Key Benchmarks to guide
  strategic assessment of your ASC

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• Profile of Participants
• Goal 50 Facilities
• Purpose
• Phase I - Design and Pilot a Proprietary Survey
  Instrument with 30 to 50 ASC Facilities
• Formulate and test validity of survey questions
• Refine survey questions including adds, deletes
  and response frames
• Develop recommendations for 2008 launch of
  member-wide survey

• Pilot survey included 46 questions - mix of
  closed and open end questions
• Facility Profile
• Medical Practice
• Clinical Performance
• Business Performance
• Participant Profile
• Challenges and Opportunities - OOSS Needs
• Participant Feedback

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• Regional Analysis

• The North-East
• 17 Facilities
• The South
• 21 Facilities
• The Midwest
• 15 Facilities
• The West
• 9 Facilities
• A total of 62 facilities completed the pilot
  survey representing 29 states

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• Framework for Discussion
• Quick Review of Results and Preliminary Analysis
• Consultant Observations and Recommendations
• Participant Questions and Recommendations

• Work-in-progress
• Member Contoured
• First Cross-Sectional - then Longitudinal
• Core Content of Survey
• Profile Questions - demographic
• Performance Questions - business/finance
• Efficiency Questions - operations/admin
• Outcomes Questions - clinical quality and patient
  experience

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• During 2006, what was the main geographic market
  that your facility served?

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• Which of the following best describes the current
  ownership structure of your facility?

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• How many operating rooms currently exist in your
  facility?

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• Clustering of Facility Size by Square Feet

• 21 Small Facilities
• 2,000 to 4,000 sq ft
• 21 Mid-size Facilities
• 4,500 to 6,500 sq ft
• 20 Large Facilities
• 7,000 sq ft

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• Key Measures - for Preliminary Comparative
  Assessment

• Business Performance - Primary measure of
  business success - Direct Cost as a of Gross
  Profit
• Clinical Performance - Primary measure of
  clinical success - Total Incidence as a of
  Cataract Procedures Performed
• Gross Profit Revenue - Total Direct Expenses
• Total Incidence Transfers Anterior
  Vitrectomy Endophthalmitis TASS

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Business Performance

• Amount Billed
• Discounts Recognized
• Amount Collected

• Aggregate Statistical Analysis

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• During 2006, what was the total amount billed for
  all procedures performed?

• Minimum 0
• Maximum 30 Million
• Mean 6,499,739.96

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• During 2006, what was the total amount of
  discounts recognized for all procedures performed?

• Minimum 0
• Maximum 11 Million
• Mean 2,085,741.05

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• During 2006, what was the total amount collected
  for all procedures performed?

• Minimum 0
• Maximum 17 Million
• Mean 3,430,128.51

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• Top Business Performers

• Small Facilities
• 4 of 21 Facilities with lowest Direct Cost as a
  of Gross Profit
• Average 8.75
• Compare to Average for 21 Small Facilities
  42.80

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• Top Business Performers

• Mid-sized Facilities
• 5 of 21 Facilities with lowest Direct Cost as a
  of Gross Profit
• Average13.61
• Compare to Average for 21 Mid-Size Facilities
  40.24

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• Top Business Performers

• Large Facilities
• 4 of 20 Facilities with lowest Direct Cost as a
  of Gross Profit
• Average 11.42
• Compare to Average for 20 Large Facilities
  39.62

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Discussion

• Pause for Discussion

• Initial Results
• Comparison by Size
• Key Business Measures
• Other

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Clinical Performance
Aggregate Statistical Analysis

• Anesthesia Services
• Sterilization
• Cleaning Procedure
• Use of a Patch
• Patient Clothing
• Transportation to OR
• Average of visits

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• Who provides the majority of your anesthesia
  services?

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• Which type of sterilization equipment most
  closely describes what your facility uses?

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• Which of the following most closely describes the
  cleaning or processing policy or procedure in
  your facility?

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• Does your facility use a patch for cataract
  patients?

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• Do your cataract patients change clothes or do
  they wear their street clothes during surgery?

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• How are your patients typically transported to
  the OR?

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• When does your facility routinely require
  patients to come to your office or some other
  office after an operation?

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• On average, how many visits are there from the
  initial exam until the patient is out of the OR?

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• Top Clinical Performers

• Small Facilities
• 5 of 21 Facilities with Lowest Incidence
• Average Rate of Incidence 0.30
• Compare to Average Rate of Incidence for 21 Small
  Facilities 1.17
• Total Incidence Transfers Anterior
  Vitrectomy Endophthalmitis TASS
• Rate of Incidence Total Incidence/ of
  Cataract Procedures

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• Top Clinical Performers

• Mid-sized Facilities
• 4 of 21 Facilities with Lowest Incidence
• Average Rate of Incidence 0.31
• Compare to Average Rate of Incidence for 21
  Mid-Size Facilities 1.60

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• Top Clinical Performers

• Large Facilities
• 4 of 20 Facilities with Lowest Incidence
• Average Rate of Incidence 0.28
• Compare to Average Rate of Incidence for 21 Large
  Facilities 1.34

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Discussion

• Pause for Discussion

• Initial Results
• Comparison by Size
• Key Clinical Measures
• Other

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• In which of the following areas could OOSS
  sponsored consulting services benefit your
  facility the most? Check all that apply.

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• Business and Clinical Challenges

• Staffing and nursing shortages
• Employee wages
• Scheduling
• Cross training
• Outdated business models
• Outdated OR facilities
• Debt
• Decreased reimbursement
• Increased cost of supplies, drugs

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• Business and Clinical Opportunities

• Increase Efficiencies
• Expansion/Growth
• Facility
• of cases
• ORs
• Specialties
• of surgeons, partners

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• Suggested Topics of Interest

• Salary, hourly pay and benefits
• More expense detail
• Surgeon time for procedures
• More complete breakdown of direct and fixed costs
• Facility accreditation
• Quality improvement issues
• How difficult to find nurses

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• Improvements and Benchmark Program Development

• Instrument Refinements
• Analyses Refinements
• Reporting Formats
• Marketing and Launch of 2008 Study - Expand
  Participants to 100, Include 50 of 2007
  Participants
• Focus on Strategic Benchmarks - Link to
  Consultation Support and Best Practices of
  Performance Leaders
• Industry Sponsorship Opportunities to Enhance
  Survey Reporting and Individual Case Analysis

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Discussion

• OOSS Sponsored Consulting
• Challenges Opportunities
• Additional Topics
• Other

• Pause for Participant Discussion

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Glenn DeBrueys - CEO, American SurgiSite Centers
gdebrueys_at_americansurgisite.com Beth Hurley,
RN, BSN, CRNO, COE hurleybeth_at_aol.com Louis
Sheffler - COO, American SurgiSite Centers
lsheffler_at_americansurgisite.com Kent
Jackson, Ph.D., Lance Jackson Associates,
kjackson_at_lancejackson.com