Kathy Wilson – Accurately Tracking & Reporting on the “Wrong Site” Measure

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

Reporting on quality measures is a complicated but critical element of running a surgery center. The measure “ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant,” in particular, poses its own set of complications for many reasons.

Kathy Wilson, the Executive Director at the ASC Quality Collaboration, has an extensive background in running surgery centers and in quality and risk management. For today’s episode, Kathy answered all your most pressing questions about this measure. A huge thanks to everyone who submitted questions in advance!

Broad Scope: Wrong-site surgeries range from minor lens corrections to severe cases like the wrongful amputation of limbs. Even a single incident is considered critical, demanding immediate response and learning.

History & Reinstatement: Initially removed due to high performance, these measures were reinstated in CMS’ Reporting Program as of 2023. It now includes data from all patients, not just Medicare, and is reported through the Hospital Quality Reporting System (HQR).

Collecting the Data: Based on your case volume, specialty mix, and budget, it is possible collecting the data manually via paper might be sufficient. However, a risk management tool or electronic process will likely be the most efficient.

Policies and Procedures: It is essential for each ASC to have clear policies and procedures for adverse event reporting and to ensure staff are well-informed about the reporting process and the significance of each measure.

Benchmarking: Want to see how you compare to your peers? The ASC Quality Collaboration offers free benchmarking data on its website, representing 2,000+ ASCs and 2.5 million patient encounters.

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

Episode Transcript

00:01.51
Erica Palmer / HST Pathways
Hi Kathy welcome to the podcast can you please share a little bit about yourself and your health care experience.

00:11.19
Kathy Wilson
Sure, yeah, um I am right now the a the asc quality collaboration executive director I’ve been doing that since January of 2021 before that I was with 2 of the asc management companies. In the quality and risk management area and prior to that had been a surgery center administrator for 15 years My background’s in nursing and I have a master’s in hospital administration.

00:32.61
Erica Palmer / HST Pathways
Perfect.

00:39.42
Erica Palmer / HST Pathways
Nice, very impressive I am really excited to have you on today because as I understand it and we’re just going to refer to it as the wrong site measure to make keep it simple. Um, but as I understand it. It’s a measure that.

00:54.63
Erica Palmer / HST Pathways
Ah, ases can potentially struggle with when it comes to understanding the intent of the measure and how to report data so that it’s both accurate and consistent and we actually source questions from our listeners via Linkedin and through Instagram and through email so we have a lot. To cover today. So let’s just get right into it. Can you please explain the quality measure and why it’s important.

01:20.19
Kathy Wilson
Yeah, Well this quality measure which is wrong side surgery is really critical to ensuring patient safety in our ess so there are a lot of there are protocols in place example is the universal protocol from the joint commission. To prevent events happening to a patient that are not what are intended. So um, we have a patient that consents to a procedure and we have an intended procedure to be performed. But if something goes off track with that. Um, it can result in the patient obviously having the wrong site side Implant etc. So We want to make sure that this is tracked so that we’re aware of when these happen so that we can address them. Um, these events we call this the measure wrong site. But as you said it includes wrong side Wrong Patient Wrong Procedure Wrong Implant wrong blocks and wrong level of pain procedures. Those are just some examples of the things that are included there. Um, so these safety protocols have to be top of mind for all the staff and all the verification processes need to just be baked in from the time the patient registers all the way through their care experience.

02:47.76
Kathy Wilson
So you know the harm that can result from these is extreme I think we all remember there was a case in Tampa at a hospital where a wrong limb was amputated. That’s the on one end of the spectrum.

02:58.96
Erica Palmer / HST Pathways
Oh geez.

03:04.21
Kathy Wilson
But a patient may have to have a lens corrected in the or if the wrong one is put in so so it’s a big variation in the amount of harm that can happen to a patient but if it happens 1 time. It’s too many our patients come in expecting things to go smoothly and if they don’t. We need to know about it quickly. We need to address it and we need to learn from it. So this is a really important measure and they’re these are preventable.

03:30.35
Erica Palmer / HST Pathways
Sure sure and I do understand that it was kind of put on pause and then recently resurrected can you just share the history of the measure and the latest as of today.

03:43.62
Kathy Wilson
Yeah, sure. Sure yeah, this measure which is a c three um along with patient burns patient falls. And all-cause hospital transfer admissions were 4 measures that were some of the original Asc measures that were developed by the asc quality collaboration and then they were adopted by Cms for use in the Asc Quality reporting program. So when we first started reporting these they were. They were reported through quality data codes that were put on medicare claims so a code was actually attached to the claim and that’s how Medicare knew that an event had occurred so when they compiled all that data and they looked at the results. The results were good. There was good performance so cms proposed that this be they be taken out of the quality reporting program because as cms refers to it. They were topped out the performance was so high so good. However, um. They got input from us from the asc community that these are really important measures to measure patient safety and just because they were type type topped out doesn’t mean that we should stop tracking them.

05:01.41
Kathy Wilson
So they reinstated these measures into the asc quality reporting program in 2023 the difference now though is we don’t use quality data codes anymore we report these through the hqr system hospital quality reporting system. Which is the method that’s used for many many of these measures on being reported to Cms and now it includes all patients not just medicare patients. So we’re back on track with it.

05:32.47
Erica Palmer / HST Pathways
Yeah, that’s interesting I feel like ah last couple years I’ve I’ve been paying more attention to like the final payment rules and things like that’s not common that someone on the Asc side is actually wanting to report on. You know all the nuances so that’s actually really interesting and very telling that it was.

05:38.77
Kathy Wilson
Are.

05:50.46
Erica Palmer / HST Pathways
You know the community that was like we really actually should be should be reporting on all of this.

05:53.80
Kathy Wilson
Yeah, yeah, yeah, we submitted comments about that and you know that’s a really important point Erica is we all need to stay very engaged in commenting when we can and giving c um cms feedback when they ask for it. Yeah.

06:07.22
Erica Palmer / HST Pathways
Definitely so 1 question that we got ah in a bunch of different ways was just obviously best practices for collecting this data and the simplest way to collect the data. We saw that that word come up a lot. So. What are your tips and advice for collecting it. Ah what would? what would you suggest.

06:24.00
Kathy Wilson
Yeah, yeah, um, you know it really depends on the Center. There’s going to be a wide variety of processes in place for this. But at the most basic. Level Everybody needs a policy and procedure related to adverse event reporting and all staff need to be really familiar with it. They need to know the timeframe for reporting what’s required. And have a simple form that can capture that information as close to the time of the procedure as possible that might be electronic, but it can very well just be on paper but everybody needs to understand the use of those forms and the forms need to capture all the critical elements. So really important that staff know that and know when to report it into whom and who to whom to submit that report and then typically that will be compiled into some risk management system that could be a very sophisticated designated risk management system. Or it could just be that someone’s responsible for tracking it on a spreadsheet. But so important to have that data to be able to track it and see how you’re doing over time so it can vary widely. But it really important that everybody knows what the process is.

07:49.11
Kathy Wilson
Whether that be manual or electronic or you know part of a whole system that the the Asc may be involved with.

08:00.30
Erica Palmer / HST Pathways
Sure and just thinking through some of those variances would it be ah, would case volume come into play like if you’re a smaller facility maybe managing it on a spreadsheet is more realistic specialties like budget kind of all of those things.

08:10.12
Kathy Wilson
Absolutely absolutely budget size whether you’re affiliated with a hospital system that has a electronic system in place. So yeah, smaller centers may just be tracking it manually and that’s fine. That’s absolutely fine. Yeah.

08:30.25
Erica Palmer / HST Pathways
Yeah, sure. Um, okay, let’s switch gears a little and talk about cms so it seems that obviously Cms has a very specific definition of what they’re looking for and what this measure is intended for. Ah, but if ases don’t fully understand those Cms parameters. They might be underreporting or overreporting. So what discrepancies have you seen there between cms and the ases understanding.

08:55.58
Kathy Wilson
You know, um, it’s a really interesting question and we’ve just been looking at this medicare actually has Cms has a definition. Um, which is a surgical or other invasive procedure that’s considered to be performed on the wrong, but body part if it’s not consistent with the correctly documented informed consent for that patient. So it includes not only surgery on the right body part. But also wrong location on the body left versus right or level so that’s a definition that you see that’s tied with Cms the actual measure specifications are not very specific so they actually state all admissions experiencing a wrong site. Ah, wrong side wrong patient, wrong procedure or wrong implant. But there are a lot of nuances as we analyze these events and they may not fall cleanly into those categories. So it’s important that we know you know what really should be considered. As part of for example, a wrong implant so that could be you know an expired implant. It could be the wrong lens is placed the wrong strength lens so there are a lot of nuances to these that have to be sorted out.

10:24.52
Kathy Wilson
When an event like this occurs. So someone may you know some centers may say for example, um, I’ve heard some centers say that it’s not reported as a wrong if the patient is still in the or when it’s caught well, that’s not necessarily true. A patient may. Have not come out of the or and require a second procedure and we would consider that a wrong. So there are nuances to it that have to be discussed and you really have to land on what you feel is the best. Um.

11:00.65
Kathy Wilson
Reporting category for that to go into. But yeah, we don’t want people overreporting but we also don’t want under reporting of it because we want to make sure that all of these are addressed.

11:12.69
Erica Palmer / HST Pathways
So sure and that’s actually perfect segue into another question that we’ve received um was what measures can you implement to educate your staff. Um, you know on the measure as a whole and those nuances.

11:22.24
Kathy Wilson
Yeah, yeah, yeah, really important that staff understand the quality reporting program and what all measures are being reported to cms on behalf of the center because that’s publicly reported and um. So. It’s important that the staff first of all knows what cms measures are but more importantly I think it’s really really important to share the stories of these events with staff when you have staff meetings or department meetings depending on the size of the facility. To share these stories and people may not be aware of what has happened in their own facility. So. It’s really important to at staff meetings take the opportunity to tell the stories of these events and if you can to talk about the impact on the patient. That’s what’s the the most important thing obviously in correcting the errors. So staff may listen to those stories and think boy that could have been me or that’s something that I do every day I need to pay closer attention. So important that they hear these. The other thing is I think that’s really effective in educating staff about these measures is to post them and you can if you have an area in the center. That’s not obviously not out in the waiting room but some place that just staff sees staff and physicians see. Um.

12:54.23
Kathy Wilson
We used to keep a big Mark White marker board with all of these measures on it and track the performance from month to month and people need to know how your center’s doing on these measures and it also prompts conversations about gosh I didn’t know we had that happen here you know and. So everybody can really relate to if it’s something that they’re working on every day and it could be them. They want to make every take every step to prevent it from happening. It has it. It takes its tool not just on patients but on staff too when these adverse events occur. So.

13:22.92
Erica Palmer / HST Pathways
Yeah.

13:30.39
Erica Palmer / HST Pathways
yeah yeah I would imagine so and I think that’s a good approach like the education about like for pragmatic reasons here’s why you need to understand this here’s what Cms is expecting but then also kind of that emotional tie in of like here’s the reality like you know.

13:32.70
Kathy Wilson
We want to prevent them for a lot of reasons.

13:48.45
Kathy Wilson
Um, absolutely.

13:50.39
Erica Palmer / HST Pathways
Yes, maybe we had to let’s say for the year and that’s a incredibly small number compared to our case volume. But let’s think about those 2 patients now that are their lives are impacted probably will be scared to have surgery again you know, whatever it might be um.

14:02.17
Kathy Wilson
And there’s a reputational component to it if what happens to a patient and they talk about it and so yeah, they’re just they’re far reaching ramifications when these occur.

14:07.73
Erica Palmer / HST Pathways
Yeah.

14:19.23
Erica Palmer / HST Pathways
Yep, Definitely what? Um, what are some common challenges that you think as Cs are facing right now and in trying to collect accurate data.

14:29.50
Kathy Wilson
Yeah I think there’s you know there’s it’s it’s just normal that there’s going to be sometimes a hesitancy to report and for a lot of reasons you know embarrassment. You know you don’t want to make. Make it look like you did something bad or that the physician did something bad, but um, when a facility has a culture of transparency. That’s not an issue because you want to bring those forward. So. That doesn’t happen overnight but building a culture of openness and transparency is really important. The other thing is sometimes it just plain creates more work. You have to so you want the reporting system to be as simple as possible when getting all the information you need. Um, sometimes you have to report them to the state. So there are a lot of places that potentially these have to be reported. But so that’s always going to be a challenge you know in some states like in Florida Physicians can get fined for a wrong site surgery. So you have to know what your state. Um, you know regulations say about the reporting and what happens to staff that are involved in these so it’s it’s natural that there’s going to be a hesitancy. But if the center creates an environment in which.

16:01.32
Kathy Wilson
There’s open discussion of you know errors that are made and people are involved then in the improvements that are needed people are going to be more apt to just feel free to report and want to report so that they they make sure that the improvements are. Or started and kept in place.

16:23.87
Erica Palmer / HST Pathways
Sure yeah, and and also I would imagine being able to track trends over time. Um, it is incredibly helpful and painting that story of of improvement of like okay you know 2022 we had x amount you know 2023 you know.

16:34.30
Kathy Wilson
Absolutely we did this? yeah yeah yeah I think another challenge Erica that people are having now really continue is continued iss with staff turnover.

16:41.21
Erica Palmer / HST Pathways
And I think telling that story is great.

16:51.38
Kathy Wilson
And more use of temporary staff. There may be an unfamiliarity with what the center’s processes are for reporting and processes in general not just for reporting. But for the verification steps and the time out and you know what is. In place at that Center. So The orientation of new staff or temporary staff is so critical in this and that just continues to be a challenge everywhere now with staffing.

17:24.13
Erica Palmer / HST Pathways
Yeah, for sure. Um throughout this whole conversation I can’t help but always think about the importance of benchmarking as well. Um, in comparison to your peers and and going back to that idea of transparency and. And it’s like yes we do have to you know report these numbers but at least at least you know can give you peace of mind if you’re looking at other benchmarking data like we are not the only surgery center experiencing these numbers and you know one 1 thing that we always try to. Ah.

17:51.77
Kathy Wilson
Um, right right.

17:56.56
Erica Palmer / HST Pathways
Really hammer home with clients and any conversations we’re having is the importance of data and having these these data-driven conversations and all of your operations should be focused around data and I think you know when we were making our state of the industry report last year I turned to the ase quality collaboration to look at your benchmarking data.

18:03.10
Kathy Wilson
Um.

18:15.74
Erica Palmer / HST Pathways
As well because you offer a tremendous amount for free to surgery centers to help let them know where do they compare to their peers. So I would love to just give you the floor for a minute and just tell us you know the data the the quality collaboration collects and all of that.

18:30.98
Kathy Wilson
That the bench are yeah yeah, yeah, we um when we first developed these measures back in before the Cms reporting started in 2012 we had all this data and we realized that.

18:33.52
Erica Palmer / HST Pathways
Yes, ah.

18:48.15
Kathy Wilson
There were no benchmarks out there. So um, the management companies that were involved in the asc quality collaboration at the time agreed that they would submit this data. Obviously it’s it’s blinded so you can’t tell which center it’s coming from or which company it’s coming from. But submitted on a quarterly basis and we started posting it publicly and because there just wasn’t and a source for it as you said anywhere else. So that data comes from about 2000 surgery centers and it’s really. Ah, a big commitment on these reporting entities on these management companies part to to submit and contribute to this. We. So appreciate it. But so anyone can go out to the Asc Quality collaboration website which is ascquality dot org. And pull that report that’s posted every quarter and it has um, ah rates per thousand procedures for most of the measures. Some of them are percentage like normothermia is a percentage but you can then take your rate and compare that. To nationally what we’re seeing with our data and it just gives you um, a place of comparison which you don’t have otherwise so are we doing poorly are we doing more normally you know compared to other surgery centers.

20:18.67
Kathy Wilson
So that’s true with all of those measures and we welcome people to use it and incorporate it into their quality improvement plans for the centers. Yeah.

20:28.69
Erica Palmer / HST Pathways
Yeah, we will definitely include a link to the website in the show notes too and I think having access free access to benchmarking data like that I’m just thinking about these admins and ceos having to go to their quarterly board meetings too and and and present on the wrong.

20:45.24
Kathy Wilson
Um, absolutely.

20:48.00
Erica Palmer / HST Pathways
The wrong site data and you know if anyone starts pushing back at least you have the benchmarking data to turn back to and say hey yes we did experience X but the average is actually y so while it’s not ideal. You know we’re not out of the norm. So um, yeah I think that’s an amazing resource that.

21:06.13
Kathy Wilson
Um, yeah, and it’s important to us that it’s available free to everybody really for all surgery centers across the country to benefit from it.

21:07.58
Erica Palmer / HST Pathways
That you all offer.

21:17.40
Erica Palmer / HST Pathways
Yeah, love it all right? Kathy last question we do this every week with our guests. What is 1 thing our listeners can do this week to improve their surgery centers.

21:30.23
Kathy Wilson
I would say go back to the basics. Sometimes that’s what we need to do and as we’ve been discussing I think you really have to just take a step back with wrong site Surgery prevention. And make sure all those verification steps the timeouts are in place Monitor. It look to see that it’s being done and that it’s being recorded as such so sometimes we can get so busy and so involved in. And intricacies of of you know quality programs but we have to go back to the basics and think about you know the impact on patients. So This is just such a key measure in maintaining patient safety. And everyone in the facility needs to understand how critical it is that if they’re assigned a process. That’s part of this that it’s carried out consistently for every single patient.

22:34.34
Erica Palmer / HST Pathways
Perfect. Thank you and thank you so much for coming on and answering all of our listeners questions. We appreciate it.

22:40.94
Kathy Wilson
Um, so you’re so welcome.