The volume of ambulatory surgeries performed in the United States has tripled over the previous three decades1 as a result of a shift from inpatient to outpatient procedures and an increase in outpatient volume.2 Seeking to create integrated health care delivery and financing systems, academic health systems increasingly are buying, merging, and aligning with ambulatory surgery centers (ASCs), community hospitals, and private practices. As a result, these academic health systems and the ASCs within them have complex organizational structures for which the governance, leadership, and management systems for the quality of care delivered are often underdeveloped or ambiguous.
The ASCs within Johns Hopkins Medicine (JHM) have experienced a similar increase in volume and complexity of cases. JHM grew from two ASCs to eight in seven years, partnered with a large number of private practice physicians, and increased the volume and complexity of ambulatory surgical cases; yet the quality management infrastructure did not grow to accommodate these changes. Driven by increasing regulatory and public reporting requirements and by the goal of making JHM a national leader in providing quality health care, the ASC leaders and physicians wanted to implement a structure to support peer learning, sharing best practices, and enhanced accountability. Creating such a structure was no easy task, as the ASCs varied in geographic location, by surgery types, and by their regulatory requirements.
The JHM Patient Safety and Quality Board Committee requires that all entities within the JHM brand report measures of the quality and safety of the care they deliver. The board assigned responsibility for coordinating these efforts to the Armstrong Institute for Patient Safety and Quality (Armstrong Institute),3,4 whose purpose is to partner with patients, their loved ones, and all interested parties to end preventable harm, to continuously improve patient outcomes and experience, and to eliminate waste in health care. The Armstrong Institute operates under the governance of the JHM Patient Safety and Quality Board Committee, which provides oversight and strategic goals, and reports to the JHM Board of Trustees.
Ambulatory surgery is diverse in the settings in which it is performed, the services provided, and the providers. The eight ASCs annually care for 10,000 patients, perform 12,000 procedures, provide 14 surgical lines, and include 131 credentialed physicians, all of whom are either surgeons, gastroenterologists, or anesthesia providers. Four ASCs are freestanding, and four are hospital based. They became part of JHM at different times and operated under different models—including community hospital, academic medical center, and independent community center—and different regulatory standards. In addition, ambulatory surgery at JHM includes multi- and single-specialty centers, single- and multiple-operating-room centers, JHM-employed and non-JHM-employed physicians, and differences in organization and operations, such as internal JHM management versus external, non-JHM management. In this report, we describe our efforts to integrate and align ASCs into the JHM patient safety and quality structure to optimize learning, ensure accountability, and reach both JHM-employed and non-JHM-employed physicians.
To create a management system to support the safety and quality of care for all patients served under the JHM brand, a council and an associated chief quality officer (CQO) position were established for each service line (i.e., ambulatory practice, home care, international medicine, inpatient care, pediatrics, population health, and ASCs). The position of CQO for clinical best practices was also created to help standardize care across all practice locations. Each CQO creates, coordinates, and oversees council efforts and provides quarterly updates to the JHM Patient Safety and Quality Board Committee. Each council shares the patient safety and quality vision of JHM leadership.
We created the JHM Ambulatory Surgery Coordinating Council in 2014 to standardize the ASCs, to create an infrastructure to support patient safety and quality in these centers, and to increase peer learning among ambulatory surgery sites. The Armstrong Institute supported and provided strategic guidance for our efforts. The only marginal cost associated with the council was supporting the new position of CQO for ambulatory surgery, a 20% effort position for a physician who would report to the director of the Armstrong Institute.4
The CQO reports directly to the JHM Patient Safety and Quality Board Committee and the JHM Ambulatory Oversight Committee (see Figure 1) regarding the work of the Ambulatory Surgery Coordinating Council. The physician-led council functions as a self-governing network charged with (1) promoting multidisciplinary interactions among JHM-employed and non-JHM-employed physicians; (2) setting the strategy for ASC quality and safety efforts, with the goal being to exceed standards on publicly reported quality and safety measures and identify new measures to report; and (3) identifying, implementing, and evaluating best practices. The council shares lessons across ASCs, creating a vibrant peer learning community.
The Ambulatory Surgery Coordinating Council has representation from all ASCs within JHM, including the medical director and nurse manager from each center and representatives from the JHM epidemiology and infection control division and the regulatory affairs division, for a total of 33 members. The council convenes quarterly for two-hour, in-person sessions to discuss the four areas of safety, externally reported measures, patient experience, and risk; to monitor performance; to ensure accountability; and to develop strategic initiatives. The council convenes separately to discuss immediate safety concerns, such as Ebola preparedness or a specific safety risk.
Council members wrote a mission statement (see below) and outlined a plan to learn from each other’s successes and failures and to gain consensus on goals, strategies, and performance measures. Their mission is to “align with JHM Quality Initiatives to provide exceptionally high quality patient-centered care at all Johns Hopkins Medicine ambulatory surgery centers.”
During the first year, the Ambulatory Surgery Coordinating Council focused on building trust amongst its members, many of whom were meeting for the first time and previously were competitors; creating governance, leadership, and management systems; and developing a common dashboard and approach to patient safety and quality. Trust developed through relationship building, inviting participation, and co-creating the mission statement, purpose, and improvement strategies and tactics. With trust, the council gained consensus from its members on the measures to collect and monitor. These measures included infection control reports and accountability measures for the Joint Commission, core measures for the Centers for Medicare and Medicaid Services (i.e., admissions/transfers, falls, burns, wrong site/side/patient, safe surgery checklist), and quality measures for the Maryland Department of Health. The council also agreed to monitor patient experience scores, such as those from the Press Ganey Outpatient and Ambulatory Surgery Patient Experience of Care Survey for ASCs, surgical site infections, and hand hygiene, and to collect adverse event data obtained from a health system incident-reporting system. Consistent with other areas of JHM, the council implemented a model for reporting these measures that is organized into the four domains of safety (internal risks), performance on external measures, patient experience, and value.
Information specialists created an intranet Web site to display dashboards of these measures, thereby enabling data distribution and transparency across the network. Since June 2014, data have been reported using these dashboards. This system supports the central reporting and monitoring of performance. The dashboard is accessible by all ASCs and contains the outcome and process measures that the members of the Ambulatory Surgery Coordinating Council agreed were significant (see above). Each ASC uploads its data into the dashboard, which is maintained by the Armstrong Institute as part of its overall health system dashboard framework.
By thoughtfully discussing which measures to collect and how to report them, the council helped to mature the process of performance reporting and to identify ways to stratify measures. For example, hospital transfer data highlighted differences between freestanding and hospital-based ASCs. Preliminary data demonstrated higher transfer rates at hospital-based ASCs. A deeper dive into the data revealed a more severe case mix at these centers, with overflow “inpatient” cases scheduled in the ASCs based on proximity. The council also discussed how best to report and monitor self-reported adverse events.
In addition, council members identified the most important topics to achieve its purpose and enhance value. Their current focus includes coordinating electronic medical records across the ASCs, aligning the centers with the health care system, developing benchmarks of performance on patient safety and quality measures, and partnering with finance to reduce supply costs.
The council is also a forum to discuss efforts to enhance patient experience and safety, in which members submit topics to be considered for focused improvement efforts. One ASC requested a review of multidose eyedrop medication use for any administration of eyedrops to patients, given that the drops are sold in multidose vials, and the group agreed on the now-standard ASC-wide practice of multidose eyedrops. Council members also agreed to standardize the complication-reporting process, previously performed differently at each location. These previous practices ranged from reliance on identification through nurse postop patient calls to direct querying of complications from surgeons. The council collated the different reporting methods and created a standard reporting form for surgeons to document 30-day complications.
As seismic changes occur in health care, academic health systems must reorganize as they align with community partners in large, multihospital health systems. In 2011, JHM created the Armstrong Institute to help transform health care and optimize value. We used this foundation to address the disparate organization of ASCs within JHM. Through the Ambulatory Surgery Coordinating Council, we created a structure to coordinate improvement efforts among ASCs, providing a mechanism for peer learning and accountability, consistent with the circular organization concept of supporting organizational democracy.5 The ASCs lead change locally, and the council provides the support needed to achieve their purpose.
Through our partnership with JHM leadership, we rapidly organized and aligned eight independent ASCs, developed a mission statement with clear objectives, and identified focus areas for improvement and integration. This convergence centered on a common desire to optimize patient safety and quality of care. The common ASC mission is to provide the highest-value care possible. A safe, standardized, efficient ASC foundation also supports the education mission of the academic health system, as learners benefit from exposure to care in an ambulatory surgery setting, with its heightened efficiencies and different patient demographic.
Our model can inform other academic health systems looking to integrate ASCs into their organizations. Currently, over 6,000 ASCs in the United States perform over 5.5 million procedures annually.6 In 2011, ASCs received $3.5 billion in Medicare payments.5 The projected shift to even more surgical procedures, including vascular surgeries,7 being performed in ambulatory settings makes this integration even more pertinent. While some academic health systems have grown and incorporated ASCs, their governance, leadership, and management systems for patient safety and quality have not been updated to mirror the rigor and accountability of their financial systems. The JHM Ambulatory Surgery Coordinating Council provides this rigor and accountability.
This organizational model led us to a fractal-based quality management infrastructure.3 In a fractal infrastructure, centers and staff are connected horizontally to tap peer learning, and centers are also connected vertically, providing accountability, with individual ASCs reporting performance measures to the Ambulatory Surgery Coordinating Council, and the council reporting performance measures to the JHM Patient Safety and Quality Board Committee. This structure allows for a bottom-up method of unifying and repeating processes throughout the system, and it balances peer learning with accountability and independence with interdependence. The ability of the Ambulatory Surgery Coordinating Council to create common governance, leadership, and management systems among the ASCs within JHM provides evidence for use of this fractal model.
The council’s partnerships with the Armstrong Institute and JHM, in particular with the community division and finance, have allowed us to lead efforts to enhance value at the ASCs. An important future direction is for the ASCs to join the JHM supply chain standardization efforts, uniting the ASCs with hospital purchasing opportunities to attain the best pricing for supplies. In addition, the partnership between all ASCs will facilitate the appropriate transfer of patients to the safest, most cost-effective environment.
In summary, we described the JHM Ambulatory Surgery Coordinating Council model; its benefits include reliance on stakeholders to achieve the three overarching safety and quality goals: to partner with patients, their loved ones, and others to (1) eliminate harm, (2) optimize patient outcome and experience, and (3) reduce waste. This bottom-up approach supports engagement from all staff, creating a structure for peer learning while maintaining accountability for results through quarterly reporting and oversight from the JHM Board of Trustees. We anticipate even greater standardization and coordination of ASCs beyond the initial achievements we have reported here as we continue to identify opportunities and collectively organize around them.
Acknowledgments: The authors acknowledge the members of the Ambulatory Surgery Coordinating Council: Marc Appelstein, MD, John Beauregard, MD, Kristen Cheung, MD, Todd Epstein, MD, Henry Jampel, MD, and Adrienne Scott, MD.
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