This Week in Surgery Centers: Debra Stinchcomb – Common Deficiencies Found in a Patient Tracer Exercise

Here’s what to expect on this week’s episode. 🎙️

How many of you feel 100% prepared for your surveyor’s Patient Tracer Exercise right now?

Debra Stinchcomb is a Senior Consultant for Progressive Surgical Solutions, A Division of BSM Consulting, and she’s joining us on this week’s episode to talk about common deficiencies she typically sees during the Patient Tracer Exercise and how you can overcome them. With 30+ years of experience, Debra has seen it all, and together we dive into:

➡️ The tracer methodology

➡️ Why it’s essential for patient safety

➡️ Common deficiencies across the patient journey – from Patient Rights to PACU

➡️ How you can pass with flying colors

➡️ The accreditation and financial impacts of getting this exercise wrong

Find the full episode on Apple Podcasts, Spotify, or YouTube to hear all the details!

0:00
welcome to this week in surgery centers if you’re in the ASC industry then
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you’re in the right place every week we’ll start the episode off by sharing an interesting conversation we had with
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our featured guests and then we’ll close the episode by recapping the latest news impacting surgery centers we’re excited
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to share with you what we have so let’s get started and see what the industry’s been up to [Music]
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hi everyone here’s what you can expect on today’s episode Deborah stitchcomb is
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a senior consultant for Progressive Surgical Solutions and she’s on the podcast today to talk to us about the
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common deficiencies she typically finds ASC struggle with during a patient Tracer exercise with 30 years of
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experience Deborah has seen it all and she’s sharing excellent tips to make sure ASCS pass this part of the
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accreditation process with flying colors in our news recap we’ll cover social
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media do’s and don’ts for surgery centers how anesthesia start times can impact your bottom line a new
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groundbreaking Surgery Center in Uganda and of course and the new segment with a positive story about the power of music
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in a hospital hope everyone enjoys the episode and here’s what’s going on this week in
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surgery centers [Music]
1:22
hi Deborah welcome to the podcast thank you for joining us you bet absolutely
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before we get started can you tell our listeners a little bit more about yourself
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well I’ve been in the ASC industry now for almost 30 years which is kind of scary to say I’ve been the administrator
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of a couple of centers I’ve also been in the RVP role for a couple of corporate
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entities and I’ve been doing consulting now since about 2012. and I’ve been blessed to be on or
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I’ve been lucky to be on the FAFSA board in the past as well as the ask a board I’ve been a triple HC surveyor I have
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chaired the joint commission p-tac and I’m currently the treasurer for Basque
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which administers the certification for administrators as well as Cape wow
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that’s extremely impressive do you have what has been your favorite role to date
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could you pick gosh all of them are I think the the
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most fun as far as outside of the work area is to just help people with running
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their surgery centers and educating them and educating their staff that’s been very rewarding yeah I bet
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that’s awesome and how about Progressive Surgical Solutions tell me a little bit more about the organization how many
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ASCS do you work with all that good stuff we have been around since about 2010
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about four years ago we merged with BSM and they are a practice management
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company so there was a lot of good Synergy between the two we do everything
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from doing a pro forma in a development project to helping with floor plans
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licensing certification accreditation we do a tremendous number of mock surveys
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we do efficiency studies really anything that’s related to surgery centers
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currently we have about a hundred current clients at various stages of of
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Contracting and we also do quite a bit to support nurse leaders I think
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everybody can agree that there’s been a shortage of nurses for a long time covid certainly accelerated that and nurse
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leadership is important as well but we have e-support which is a web-based
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subscription that that provides all the mandatory education someone needs policies and procedures a forum for
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people to ask questions and just a tremendous number of resources and tools
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to make things easier for the surgery center we also have a Facebook page for nurse managers which has over 650 people
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who have joined that so they really get to interact and share a lot of ideas and
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last but certainly not least coming up is our third annual nurse leadership
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conference and that’s in Dallas on April 27th and 28th and it really is focused
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to toward nurse leaders to help them with developing themselves their staff
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and giving them some tools to do their job wow that’s a that’s a lot of uh you
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know industry education you provide and so many great resources do you find that
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with those hundred clients or so do they kind of come and go as needed or do they use your services for an extended period
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of Time how does that work a little bit of all of the above some meet us just for a short time maybe they’ve had a
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survey that has not gone well and they need some help getting up to speed it
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could be that they would like us in to help them with their compliance long term so it’s really all across the board
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that’s great that you can be so flexible too to just kind of help them wherever they’re at absolutely so thank you for all of that
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background um today we’re going to dive into the Tracer methodology which I’m super
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excited to learn more about myself I’m sure our listeners are all very familiar
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with it as it’s part of their accreditation process but could you give us kind of a high level summary of what
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the Tracer methodology is absolutely this is when the surveyor
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looks at the entire surgical throughput or process that the patient goes through
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and they look at all of the tasks that are associated with that any starting
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with pre-op maybe the pre-op call if they do a pre-op call but they look at the documentation they look at
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medication administration they look at instrument processing they look at
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everything all the way through wow that’s awesome and what is kind of
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the goal do you think it has a positive impact on patient care it absolutely has a positive patient
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impact so the surveyors are watching to make sure that the staff are adhering to
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their policies as well as adhering to the requirements of their state
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licensing organization if they’re State licensed Medicare joint commission and
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of course there are a lot of other bodies such as Amy aorn OSHA you know
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there’s a lot for people to know so it’s a great way to look for any gaps between what’s required and what they’re
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actually doing so it can provide an educational opportunity for the surgery
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centers not only do the accrediting organizations do it but if you read the
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Medicare conditions for coverage the interpretive guidelines the first section of that document uh tell certain
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tell surveyors what they are supposed to do when they go to a surgery center and there is a portion that’s devoted to
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what they’re supposed to do when they watch the patients through the process so it is required of your Medicare
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survey as well as your accrediting body surveys too and it’s just to step up
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from you know the old time way of just coming in and looking at all the policies and procedures you can look
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Stellar on paper but once it comes down to Patient Care are they really doing things the way that they’re supposed to
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do them yeah it sounds extremely thorough too right it seems like and they and everybody takes it very this
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part of it very seriously absolutely absolutely yeah so with all
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this firsthand experience that you do have and helping clients kind of prepare for that moment where the accreditation
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body shows up and is ready to observe a case um I’d imagine that you’ve seen a lot of
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the same common deficiencies that could be easily fixed um so let’s start at the beginning with
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patient rights what kind of errors are you seeing there that our listeners could could work on
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you bet so take a look at your admission process you know it’s very busy uh a lot
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of documents usually have to be signed in that process but where we see people
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struggling a little bit is patient rights have to be given verbally and in writing that’s a quote that’s from CMS
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and many times surgery centers provide the information they have a form that
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patients sign saying oh yes I received it but if you ask the patient have you received a copy of your patient rights
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they may not even know what you’re talking about so just make sure the front office staff really understands
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that the other issue we see sometimes is around Advanced directives so the
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majority of surgery centers will resuscitate a patient should the worst thing happen in a patient code even if
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they have an advanced directive and sometimes we find the front office is not aware of that fact
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and their role is typically to make sure the patient understands the advance
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directive policy of the surgery center so just make sure your entire team
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really understands what an advanced directive is the impact of a patient comes to them with one and how to
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explain what that policy of the ASC is to a patient without scaring them or
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worrying them okay yeah that’s that’s really interesting and I it’s like you know
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just so important that they can get get those those two things right anything else with the patient rights part
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no that’s really the admission process okay that’s good to know
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um okay so next would be the pre-op process what tips do you have for uh ases in that area
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that pre-op is probably the busiest area in a surgery center and
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believe me all areas are busy no one is sitting around twiddling their thumbs but within an hour’s time frame think of
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all the things that happen there so they’re brought in the patient has to change their clothes put on their hat
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take care of their belongings the nurses assisting them with all of this and IV has started perhaps they’re given admin
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medication or eye drops uh The Physician has to see them the anesthesia provider
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has to see them the RN is also making sure that everything is correct in that
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patient file so that’s a lot to happen and a lot of people touch the patient within that hour so there are some
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things that do go a little off track um nurses have to make sure that that
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hmp is current depending on what their policy states you know what is current for your ASC
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and are you meeting it and a current hmp does not merely mean changing the date
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of an old as of an old hmp and we do find that happening it means they have to do a brand new history and physical
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and yes it is watching the surgeon and making sure that they complete all of their paperwork the other thing we see
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is a surgeon does come out to pre-op marks the site but does not really ask
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that patient if their hmp has changed since they saw them last and they really need to do that number one they have to
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document it and that documentation should match what they actually do in
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practice and secondly they’re asking that for the purpose of ensuring that
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the risks the Alternatives and the benefits of the surgical procedure they’re having are still intact so if
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something has changed since they did the hmp a week ago is that going to impact the recovery for that patient or the
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surgery medication administration is very important in the pre-op area if staff
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are drawing up any medications that are to be used they need to be mindful that
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those have to be used within an hour so people cannot draw up a lot of
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medication at the beginning of the day and use it throughout the day it has to be used within an hour we also use this
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time for example if a patient is diabetic and they’re using the glucometer we make sure we watch the
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staff that they do the testing appropriately and that they clean the glucometer appropriately making sure
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anesthesia comes in and sees the patient and does a full evaluation so again that
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pre-op area is very very busy um and one last thing in the pre-op area
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that’s important if there is something that’s going on with the patient of course the nursing staff should report
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that to the surgeon or the anesthesia provider and we see them do that most of the time but they forget to document it
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and it kind of goes back to that old adage if it’s not documented it’s not done especially if it has a you
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know huge impact on that person or if they get a verbal order they need to make sure that they document that verbal
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order per their policy gotcha and when you say something might be going on with
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the patient can you give me an example there uh let’s say they are allergic to a
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certain medication that was not known beforehand gotcha and it might have an impact on anesthesia that nurse would
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certainly report that to Anesthesia but should also write that you know reported
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to Anesthesia you know patient allergic to blank no orders received so it really should show
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that entire care process sure yeah that makes sense and I understand the
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importance of double checking that h p the day of but do you typically find that there are changes or something the
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patient has forgotten or is it usually consistent usually it’s very consistent okay you
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know with their patient populations we don’t have a lot of comorbidities
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usually so they are pretty consistent but the key is they still need to do the
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asking for sure yeah that makes sense okay pre-op super busy
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lots of things to check there all of that all that tracks um okay so following along with the
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patient Journey let’s talk about the or next what tips do you have there what what deficiencies are you seeing
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um when you’re talking with your staff make sure that timeout process is valid that everyone is listening and
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really currently I would say 99 of the people do it appropriately but there
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still are some centers or maybe anesthesias dealing with their circuits
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and they’re not really engaged in what else is happening in the room so just to make sure those circulating nurses
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really have the ability and the responsibility of stopping everybody in
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the room to make sure that timeout is done another thing we see is the surgical
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prep uh very common for people to wipe off a wet prep instead of letting it dry
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the appropriate amount of time again we’re all trying to push quickly and move through
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the process but making sure that they’re educated on why that’s needed and what
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needs to be done another thing I see is the use of safe surgical checklist this used to be a
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Medicare requirement it no longer is but many ASCS still use one which is
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terrific it’s a great tool to use it’s a great checklist you know have we done everything correctly and oftentimes I’ll
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see people check it off but they’re not really going through the process uh for example there’s usually a question at
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the end of the surgical process that says is there anything that we need to
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make sure the recovery room staff are aware of I usually see that checked off but it’s not always asked so just making
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sure that people are really adhering to what they’re doing making sure everything matches again it’s all about
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patient safety so is everything being done in accordance with that
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in addition in the operating room and you’ll see this detailed in the CMS conditions for coverage the surveyors
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will follow the instruments so to speak now they may not have a chance to do it with that particular patient but they
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will go to Sterile Processing so just making sure that all of the instrument
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processing policies and procedures are current and adhered to in addition the
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surveyors will hang out either in that room or in another room to see how the
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operating room is disinfected to make sure that that’s also appropriate
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okay all of that makes sense do you find that the or is where they spend most of
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their time the surveyors or is it kind of spread out equally I would say it’s spread out now Sterile
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Processing though is a huge area okay so I would say you know even though that’s
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not technically following the physical patient that’s certainly part of the patient process and I would say the
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majority of the time is spent in sterile process okay that’s good to know okay and lastly let’s talk about the
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pacu what deficiencies are you seeing there and what can our listeners focus on
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sure pacu staff are excellent it also is
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a busy place because they are getting patients up dressed making sure they’re awake maybe giving them something to
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drink the biggest areas we find here and it’s not necessarily unsafe they come
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from other places maybe the frequency of their Vital Signs taking is different
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than what the policy of the ASC is both safe just different so it’s important
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when you have new staff and let’s face it we are all dealing with a lot of Staff turnover the last couple of years
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make sure that they’re aware of your particular policies that’s an important
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one because it could still be a deficiency even though it’s not against a regulation it’s still not with your
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policies we also see an issue with communication in the pack you just like I mentioned with the pre-op if something
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is going on with a patient you know high blood pressure low blood pressure whatever the case may be the
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documentation of the communication that occurs does not always happen for instance when we do mock surveys I have
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witnessed that then I go back to that chart and it’s not written down so it’s
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imperative that nurses go back to kind of a nursing 101 that they learned in
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school about the importance of documenting absolutely everything and if they receive verbal orders to make sure
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that those are documented as well but those are probably the two biggest
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issues perfect and and you’ve mentioned you know the importance of documentation and charting a couple times do you find
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that uh obviously you know paper versus electronic charting is a huge conversation that comes up all the time
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do you find when it comes to uh the Tracer methodology and all the documentation and stuff do you find that
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it makes it a difference how the the surgery center charts
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yes and no I mean there are so many different paper charts there are so many different electronic records I think the
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key there is to make sure it fits your surgery center and I know that’s just kind of a blanket statement but you need
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to make sure that there are prompts uh that clear documentation happens
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sometimes with electronic what I don’t see is uh you know maybe a drop down for
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not applicable so if you have a facility print off a record it might look like
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the staff uh does not necessarily do something when in fact they did but they
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just didn’t have an option to document that so I think regardless of the EMR
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it’s important for them to make sure it works for them and the rules are really the same between paper and a computer
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sure you know the requirements to have everything there are the same from a
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risk management standpoint for sure yep definitely the end goal yeah that’s great Insight
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um okay so we made it through the patient Journey now let’s say um you know surgery centers aren’t able
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to get some of these areas up to speed um what are some of the impacts of that
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typically they’ll get a deficiency let’s say they don’t do the timeout correctly or maybe the prep or patient rights
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Administration they’ll just have to do a plan of Correction and make sure they
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educate their staff and complete that plan of Correction certainly if they are and luckily 99.9
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percent of ASCS out there want to do the right thing but if it’s a surgery center
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that may not have the resources to devote to doing things correctly they could end up with a patient adverse
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event uh if it’s an unsafe situation which of course could be a lawsuit or an
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immediate Jeopardy situation and again going back to the CMS conditions for
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coverage it’s very clear in there and it tells the surveyors if you walk in and
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of course I’m paraphrasing but basically if you walk in and it’s an unsafe situation for patients you can call an
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immediate Jeopardy which means everything comes to a stop so it is important to take those deficiencies
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seriously and improve things at your staff level perfect and I’m just curious
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in your career how many immediate jeopardies have you seen
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luckily related to this that’s good news
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[Music] and it’s just rarely that unsafe not
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saying they don’t happen I personally have never seen them yeah for sure okay last question we do this every week with
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our guests what is one thing our listeners can do this week to improve their surgery centers
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plan to do a mock tracer clinical directors or administrators
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follow a patient through the process you would probably be surprised what you
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find because you’re certainly looking at your clinical records you’re looking at all your logs you probably pop quote
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unquote into the back and out again but following a patient all the way through really gives you a very different
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viewpoint on where there might be gaps in education and resources for your team
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perfect all right well thank you so much for joining us today Deborah you are an
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incredible wealth of knowledge and I appreciate your time and sharing all of your expertise with us
23:45
Erica thank you for the opportunity all right [Music]
23:52
as always it has been a busy week in healthcare so let’s Jump Right In the
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February edition of ASC Focus came out last week and as always it is filled with great articles and advice for
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surgery centers one of the articles that caught my eye focused on social media which has long been a topic of
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controversy for ASCS historically ACS have either really
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leaned in understanding the power of free marketing and connecting with their communities or they’ve really shied away
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from it out of concern for a legal implication and usually lack of resources as well
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so for those who do want to get involved though the article lays out some very clear do’s and don’ts so let’s start
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with the dues uh the first one is to post regularly but not too often
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publicized Community involvement review your data meaning pay attention
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to what posts are performing well versus ones that aren’t and lastly do you do
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need to know the laws it’s recommended you consult with an attorney out of an abundance of caution to make sure you’re
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following the rules and a few don’ts that they shared uh don’t rush to post photos don’t ignore
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comments which is a great tip uh don’t be quick to punish employees for things that they might be posting on
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their personal pages and lastly don’t neglect your accounts after creating them it’s really easy to
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start a social media page and then kind of loose steam lose excitement and stop posting but you do want to make sure you
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keep them active even if you’re just posting once a week so I do recommend reading the full article we’ll put the
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link in the episode notes but um just something to keep in mind that social media might be something your
25:40
surgery center wants to take on in 2023 our second story comes from or manager
25:47
and they’re sharing a report from the Northwestern University McGaw Medical Center in Chicago
25:54
researchers analyzed roughly 40 000 procedures and of those about 69 percent
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recorded the anesthesia start time as starting once the patient was in the OR
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however by doing so they didn’t factor in the anesthesiologist’s pre-op prep
26:13
time which includes talking with the patient administering pre-meds and other
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work that took place prior to the patient arriving in the OR um now this oversight is estimated to
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have translated to roughly 638 thousand dollars in Lost revenue and
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one year alone so what’s the solution the first is just educating anesthesiologists
26:39
um but step two is to include an anesthesia start time capture function into your ehr’s mobile app so that the
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anesthesiologist could record their start time on the way to the or you could set the EHR to automatically
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add two minutes to the log time for you so just something to keep in mind when
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recording start times and another reason to move away from paper and to
27:04
electronic charting the next story is really inspiring and exciting New York city-based Mount Sinai
27:11
has partnered with chibera Surgical Center the first ASC in rural Uganda
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the Mount Sinai diversity Innovation Hub launched in 2019 to help provide
27:22
adequate Health Care to underserved populations and they are doing just that
27:27
the surgery center provides much needed Health Care to this area of Uganda specifically safe and affordable
27:34
surgical procedures previously members of the community would have to travel hours in order to
27:41
have pretty pricey procedures done so the combination of high costs and time
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and travel would ultimately leave them with only one option which was to not
27:51
have the procedure done at all thanks to this partnership though that will no longer be the case
27:57
a few other really cool things about this surgery center it’s almost completely run on surgery on solar
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energy they collect and repurpose rain water they have their own gas
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infrastructure so they’re almost completely self-sustainable which is
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really important for this area of Uganda as resources aren’t always reliable
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and last but certainly not least physicians at the surgery center will be equipped with hololens technology which
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is a wearable camera that allows Mount sinai’s New York surgeons to watch procedures and provide feedback in real
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time so overall this is really an amazing initiative that Mount Sinai has taken on
28:38
and I hope more surgery centers like this can be built around the world again we’ll include the link in the episode
28:45
notes I highly recommend checking out the videos they’re on YouTube as well you can see the surgery centers you can
28:51
hear from the administrators that are working there and it’s all it’s all really cool
28:58
and to end our new segment on a positive note Charles Esten best known for his
29:03
role in the TV shows Nashville and more recently Outer Banks has been making his
29:08
way around HCA Healthcare facilities entertaining patients with live music
29:14
Ians on call is a non-profit that brings live and recorded music to the bedsides
29:20
of patients families and caregivers and thanks to their recent partnership with HCA who by the way generously donated
29:29
one million dollars so many patients are experiencing the joy and benefits of
29:34
live music um and this organization has been around for more than 20 years and has been
29:40
using music to promote and kind of complement the patient’s healing process ever since uh to learn more about this
29:47
wonderful organization again check out the episode notes or head to musicians
29:52
on call.org and that news story officially wraps up this week’s podcast thank you as always
29:59
for spending a few minutes of your week with us make sure to subscribe or leave a review on whichever platform you’re
30:06
listening from I hope you have a great day and we’ll see you again next week
30:12
[Music] why are you keeping me