Proving patient safety
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Workbook will guide office-based dermatologists to better practices, accreditation

Despite an outstanding record of safety (see www.aad.org/dw/monthly/2012/july/trained-for-the-task), dermatologists are still fighting to prove to state regulators and payers that their performance of medical and surgical procedures in the office setting adheres to the highest standards of patient safety and quality. “Although quality and patient safety are sometimes expressed anecdotally, the regulatory environment is moving toward measurements,” said C. William Hanke, MD, MPH, clinical professor at Indiana University School of Medicine and chair of the Academy’s Ad Hoc Task Force on Office-Based Surgery. In addition, he noted, with increased requirements for quality reporting to both earn incentives and avoid penalties being implemented by both Medicare and private payers, those payers “are showing their interest in reimbursing for quality care.” (Learn more about performance measurement and quality reporting at www.aad.org/education/performance-measurement-and-quality-reporting.)

Lisa Garner, MD, clinical professor of dermatology at University of Texas Southwestern, AAD vice president, and task force member, confirmed that dermatologists are “constantly challenged on the state level, in particular, about procedures that can or can’t be done in an office setting.” Some state laws and proposed pieces of legislation and regulation, she said, are extremely restrictive. “So we feel like the more our members can show that they have policies and procedures in place, that they know what quality patient care is, that they know what risk management is, the stronger they can be in fending off challenges, especially at the state level.” [pagebreak]

One powerful defense for dermatologists against onerous state-based regulation of office-based surgery is accreditation through an organization such as the Accreditation Association for Ambulatory Health Care (AAAHC) or The Joint Commission, said the task force members. “Every year we read about different states requiring that certain procedures be done in an accredited setting,” said Jerome R. Potozkin, MD, a dermatologic surgeon practicing in California and former AAAHC surveyor. “There are constant threats to restriction of scope of practice for dermatologic surgery based on office accreditation.” To assist dermatologists in office-based practices in achieving accreditation, and to support any dermatologist seeking to measure and enhance quality and patient safety, the task force has developed a workbook, which will be available to AAD members this winter, that provides practical guidance and solutions.

Comprehensive content

Broad in scope, the Patient Safety and Ambulatory Care Workbook addresses most areas of a practice that would be scrutinized in the accreditation process. “It’s modeled after the type of policy and procedure manual you would need to get accreditation from AAAHC,” Dr. Garner said. “The idea was that we would create this as a resource for members who have not yet decided to seek accreditation as an outpatient surgery center by the AAAHC,” but might decide to do so in the future.

The bulk of the workbook, Part I, addresses seven topics:

  • Governance: rights of patients, credentialing, and privileging.
  • Human resources: safe working environment, employee behavior and appearance, sexual harassment, equal opportunity employment, performance appraisals, and HIPAA compliance.
  • Quality assurance program: quality improvement, risk management, quality studies to teach problem-solving skills, peer review, incident/adverse event reporting, and patient grievances.
  • Medical records: contents, patient history and physical exam, record retention, and abbreviations.
  • Infection control, OSHA, and safety: framework for infection control, identification and reporting of notifiable infections, OSHA enforcement, safe administration of medication, controlled substances policy, accountability, and disposal.
  • Environment of care: emergency management and preparedness, equipment safety and biomedical inspection, and structural safety.
  • Clinical practice: handling of laboratory specimens and excised tissue.

Part II of the workbook provides five safety checklists, and Part III, the appendices, provides sample forms and templates corresponding to each of the seven major topics covered in Part I, as well as additional resources like the full American Society of Dermatologic Surgeons’ Guidelines of Care for Tumescent Liposuction.

Some of the content is available through other AAD resources such as the CLIA manual, the OSHA manual, and the Office Policy and Procedure Manual, said W. Patrick Davey, MD, MBA, a dermatologist practicing in Scottsdale, Ariz., and one of the original AAAHC surveyors. “The nice thing about this is that it pulls it all into one place rather than several different manuals,” he noted, adding that some of the content will be new to many dermatologists. “The material on the rights of patients, for example, might be something that we don’t offer in other places. Also, we specifically addressed tumescent liposuction because that’s where people are having difficulty; dermatologists have a hard time getting privileged to do that in a hospital surgery center. That’s also why you see a lot on laser procedures, because lasers are another area of contention.” He noted that rather than being facility-focused, “the workbook is more concerned with the way you do things. Our focus is the quality of the patient care you provide, how you prove that, and going forward, how are you making yourself better at what you do.” [pagebreak]

Noting that the workbook contains “a lot of very well thought-out policies and procedures that most of us could incorporate in to our practices,” Dr. Garner cited patient safety checklists that would become especially important when a dermatologist delegates particular procedures to a non-physician clinician. “I’m very much a control freak — I do all my own biopsies, my own anesthesia — but in some offices, a physician has someone else do the biopsy,” she said. “In a training program, a resident might do it. The patient safety checklists help ensure, for example, that you biopsy the right lesion.” Under the topic of risk management, the workbook defines and discusses informed consent and informed refusal, and includes a sample consent form. Identifying patient communication and documentation as “the two pillars of office risk management,” the workbook includes a list of the top 10 best practices for each. “This would be important to any dermatologist — we often think patients understand what we’re telling them, and we find out later that they don’t,” Dr. Garner said.

The procedures and forms relating to credentialing and peer review could be especially helpful for dermatologists who have not worked on a hospital staff, Dr. Potozkin said. “I think probably the whole administrative and credentialing process, the thought of doing peer review, is unusual for someone who’s never looked at this before,” he noted. “As a practicing dermatologist, even if you’re in a group practice, peer review is probably never done, whereas working in an accredited office, I have an outside peer reviewer come in, review charts, and go over problems. Quality assurance and risk management are also not something one would likely think of on a daily basis, but they’re essential to accreditation.” [pagebreak]

Implementation advice

Although the workbook was designed as a resource tool to help members achieve accreditation of a surgical practice, some of the task force members maintained that portions of the book are of value to all dermatologists. “I think there’s information in this book that can be used in any type of practice,” Dr. Garner said. “All of us do procedures: everybody’s doing biopsies, and most do simple excisions. The human resources content that talks about employee relationships, behavior, the prohibition of sexual harassment all of these would be good to have as general office policies and procedures. I think it helps not only dermatologists beginning new practices, but also those with established practices who want to update their policies and procedures manuals. I’ve been in practice more than 25 years, and there are things in this workbook that I intend to use in my own office, even though I don’t have a surgical practice.”

Though the sheer size of the document may be daunting, dermatologists can take a step-by-step approach to its implementation, choosing only those sections that are relevant to a particular practice, the task force members said. “I would just take it and go through it from the very beginning, edit it, and tailor it to your individual practice. I think it’s pretty straightforward,” Dr. Davey said. Members need to be aware of specific requirements in their states and adjust the procedures and forms accordingly, he added. “Most of these will be sort of minor tweaks, not a major overhaul. For example, your state might say that you can only infuse so much lidocaine during liposuction, or you might only be able to remove, say, 500 or 1,000 CC’s.” Although implementation of the workbook may be easy because the policies and procedures are laid out in detail, “you better be sure you read it,” Dr. Davey warned. “Because what I do as an AAAHC surveyor is come in and say, This is what you say you do in the policy and procedure manual is that what you’re doing?’ I’m especially suspicious if I read this manual and I see a [COMPANY]’ here and there, and it doesn’t name the organization I’m in. It means they forgot to change it, and I’m going to say they probably didn’t read this.” [pagebreak]

Also speaking from his experience as an AAAHC surveyor, Dr. Potozin agreed that when surveyors visit a practice “and they see you have these big books of policies that have nothing to do with your practice — maybe they contain policies about inhalation anesthetic agents, or endoscopy — they’re going to see that it’s just a cookie-cutter policy that you’re not even using.” Implementing the workbook is probably not a one-person job, he noted. “I would take it one chapter at a time, and use it in conjunction with the standards book published by whatever accrediting body you’re going with.” Another approach is to review the table of contents, pick one area that may be useful, and start there, Dr. Garner said. “If you take that large book and stick it in front of somebody, they’ll be overwhelmed. Read the introduction, the goals of the workbook, and then choose the things that could potentially benefit your own practice and start there." 

Dr. Hanke suggested viewing the workbook as a resource “with both obvious and less obvious implementations. Feel free to take it a section at a time with whatever serves your practice best. However, realize that the comprehensive information can prove more useful as you use it. As you dedicate yourself to identifying quality care, you will notice how much you already do, and this workbook can help you support your current efforts.” [pagebreak]

The workbook is free to AAD members and will be available through the Academy’s patient safety Web page, www.aad.org/education/patient-safety. Members can download the entire document as an e-book or download only the portions and/or forms that are relevant to their practice. If members are interested the Academy would provide a print version of the book for a cost, said Kristina Finney, manager of quality and patient safety resources. She added that the workbook and the revamping of the patient safety Web page are manifestations of the Academy’s growing emphasis on a culture of patient safety. Dr. Hanke concurred, noting that “a culture of patient safety is one which is proactive, and tools like [the workbook] are needed by dermatologists to both prevent and address safety issues. Utilize the resources however they best help you, but always reach out to the Academy when you have feedback or suggestions of what could support your practice.”