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September 2017

ASC Disaster Response: A Case Study

ASC Disaster Response: A Case Study

By ASC Management, Leadership No Comments

This is the second part of a two-part blog series on ASC disaster response by Diane Lampron, Director of Operations. Click here for part one.

In the blink of an eye, a completely normal day in your ASC, can be upended by a natural or man-made disaster. And it can take days, weeks, or months to return to your pre-disaster routine.

Emergency preparation is not only critical for an effective ASC disaster response, but, as we previously discussed, it’s a Medicare requirement for ASCs. Part of proper preparation is revising your emergency plan based on your response to drills, tabletop exercises, and emergency events. Every revision should improve the helpfulness of your plan. Understanding what it’s like for another ASC to respond to a disaster can further your ASC disaster response preparation.

Below are some of the critical steps taken during a Colorado ASC’s response to a ruptured pipe. The subsequent flooding caused substantial damage throughout the ASC. Areas flooded with the equivalent of sewer water included the waiting room, front hallway, registration desk, pre-op, and recovery room. The sub-sterile area also suffered significant damage. Thanks to a strong, tested emergency plan, hard work by staff, and outside support, the ASC re-opened to full capacity in three months.

Immediate ASC Disaster Response

Steps taken upon discovery of the flood and damage included the following:

  • Called the disaster code
  • Activated the emergency management plan (EMP)
  • Contacted fire department (which turned off water)
  • Ensured there were no patients, visitors, or personnel requiring evacuation.
  • Closed front entrance
  • Notified ASC leadership
  • Assessed affected areas
  • Took pictures of damage
  • Set aside damaged items/equipment (for insurance purposes, this included items that caused the damage, such as a broken sprinkler pipe)
  • Moved unaffected equipment away from damaged areas
  • Notified property insurance carrier
  • Rerouted deliveries

Activating the EMP

Activation of the ASC’s EMP triggered the following actions:

  • Established incident command team
  • Identified who would fill the roles identified in the EMP – Role assignments are critical. Each role guides the activities required to address all aspects of the disaster, from suspension of business operations to the response and through recovery.

Roles assigned included incident commander and staff (e.g., safety officer, infection preventionist, public information officer) as well as sections for operations, planning and logistics, and finance/administration. If you are not familiar with the responsibilities of these positions, the Federal Emergency Management Agency provides helpful resources here. Note: Some of the activities that took place under these sections are discussed below.

  • Developed incident action plan which established objectives throughout response to the incident and underwent regular updates as recovery progressed
  • Notified the facility’s governing board


The following steps were taken to disperse information regarding the incident and closure:

  • Changed telephone greeting
  • Posted notice on center’s website
  • Notified physicians’ offices
  • Notified the state’s Department of Public Health
  • Issued press release
  • Notified the state’s Department of Fire and Life Safety
  • Notified the facility’s accreditation organization

Disaster Recovery Work

The project was separated into five phases to be completed prior to a re-opening phase:

  1. Mitigation/ restoration
  2. Safety
  3. Demolition
  4. Rebuilding/construction
  5. Risk reduction


Steps taken included the following:

  • Restoration company commenced water cleanup and mitigation activities working 24/7 to mitigate further damage
  • Industrial hygienist conducted assessment and took samples
  • Infection control risk assessment (ICRA) performed


Steps taken included the following:

  • With fire sprinklers offline, fire watch implemented
  • Conducted and documented fire watch walkthrough every 30 minutes during recovery period
  • Created signage for emergency fire exits


Steps taken included the following:

  • Brought in contractor for demolition and construction phases of the work
  • Obtained permits needed for demolition and renovation/construction


Renovation plans previously scheduled for a future date were incorporated into the disaster recovery work to save on construction costs.

Risk Reduction

Planning included efforts to help reduce the risk of a reoccurrence. For example, additional insulation was installed and a new checklist was created for facility personnel to follow when investigating leaks.

Incident Command Officers and Sections

The incident command officers and sections oversaw the ASC disaster response work described above. Additional responsibilities are described below.

Safety Officer

The safety officer performed the following tasks:

  • Daily walkthroughs for interim Life Safety measures, ICRA, and hazard control risk assessment ensuring corrections were made as needed
  • Daily count of narcotics and medication storage security checks

Infection Prevention Officer

The infection prevention officer performed the following tasks:

  • Daily ICRA assessment walkthroughs
  • Ongoing communication with industrial hygienist regarding assessment and safety tests

Public Information Officer

The public information officer performed the following tasks:

  • Issued regular press releases providing updates on repairs
  • Kept website notices and telephone greeting current
  • Developed wayfinding signage and maps
  • Provided weekly briefings with facility employees

Planning and Logistics Section

The planning and logistics section performed the following tasks:

  • Determined staff availability and work assignments
  • Determined staff pay structure during recovery
  • Worked with local hospital to accommodate ASC patients and coordinate ASC staff support
  • Provided hospital with necessary supplies, equipment, and instrument sets to accommodate procedures rescheduled from the ASC
  • Identified replacement items to be ordered immediately due to lag time in ordering and delivery (e.g., cabinets, counters, doors, carpeting)
  • Maintained communication/phone system and information technology (IT)
  • Coordinated re-establishment of services (e.g., housekeeping, waste removal, linen)
  • Maintained “disaster book” of all response activities

Operations Section

The operations section performed the following tasks:

  • Obtained temporary storage for unaffected equipment that required relocation
  • Identified need for replacement equipment and IT
  • Ensured the hard drives of damaged computers were stripped/wiped before disposal
  • Developed risk reduction plans

Finance/Administration Section

The finance/administration section performed the following tasks:

  • Conducted walkthrough with insurance adjustor
  • Compiled all invoices to be paid
  • Tracked lost revenue
  • Provided cost analysis and cash flow data to governing board
  • Provided insurance carrier with all requested information (e.g., projection of business loss amount, list of damages, photos)


The following steps were taken to ensure a successful reopening:

  • Conducted mock patient walkthrough of new space
  • Posted required documentation previously removed (e.g., ASC license, patient rights and responsibilities, HIPAA, accreditation certificate)
  • Reinstated facility logs (e.g., refrigerator temperature, malignant hyperthermia cart check, defibrillator test and cart check)
  • Changed telephone greeting and website notice
  • Issued press release
  • Planned, publicized, and hosted open house
  • Celebrated re-opening and facility’s return to normal operations!

You Can Never Be Too Prepared

As I write this, Hurricane Harvey has wreaked havoc on Texas. Fires are consuming hundreds of thousands of acres across multiple western states. Hurricane Irma has Florida in its crosshairs. There is no shortage of news about the extensive damage that occurs in the wake of these disasters.

On a positive note, there are reports highlighting the improved preparation and response effort thanks to lessons learned from disasters like Hurricane Katrina and Rita. There will undoubtedly be lessons learned from Harvey and Irma that will help with future disaster planning.

Hopefully the Colorado ASC disaster response outlined above helps your surgery center identify opportunities for its own preparation improvement. If your ASC experiences a disaster, I encourage you to share your own response efforts. Relaying your story to an industry publication or presenting on it at a state or national meeting could ensure other ASCs benefit by learning from your experience.

I will leave you with this key takeaway. You cannot plan for everything. However, the more you prepare, the better off you should be when faced with the unexpected.

Diane Lampron, Director of Operations

2017 OAS CAHPS: Should Your ASC Implement CMS’ Survey in 2017?

2017 OAS CAHPS: Should Your ASC Implement CMS’ Survey in 2017?

By ASC Management, Payor Contracting No Comments

The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Provider and Systems (OAS CAHPS) collects information about patients’ experiences of care in ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). The survey gathers patient perceptions related to communication and care provided by surgery staff, expectations prior to surgery, and planning related to discharge and recovery. Enforced implementation of the survey has been delayed until 2018, with the specific date being released this November. Surgery centers across the country are deciding if they should implement the survey as planned, or wait until the Centers for Medicare and Medicaid Services (CMS) begins enforcing survey implementation.

To assist in decision making, it’s helpful to review information regarding the OAS CAHPS Survey.

Why is CMS developing this survey?

  1. The number of ASCs has increased considerably in recent years as has the surgical case volume at both ASCs and HOPDs.
  2. Medicare expenditures from outpatient surgical sites for ASCs and HOPDs also continues to rise.
  3. Implementation of OAS CAHPS will provide CMS with statistically valid data on the patient experience to inform quality improvement and comparative consumer information about outpatient surgery facilities.

The results of the OAS CAHPS will be used to:

  1. Provide CMS with information for monitoring and public reporting purposes,
  2. Provide a source of information enabling prospective patients to make informed decisions in outpatient surgery facility selection, and
  3. Aid facilities with their internal quality improvement efforts and external benchmarking comparatively with other facilities.

What modes are available to administer the OAS CAHPS?

  1. Mail only
  2. Telephone only
  3. Mixed mode (mail survey with telephone follow-up of non-respondents)
  4. An electronic mode of surveying is currently under review.

How often is the OAS CAHPS administered?

  1. Surveys are administered on an ongoing basis.
  2. An annual minimum of 300 surveys must be completed for each facility.
  3. Participating facilities will provide a monthly sample of patients who received at least one surgery or procedure during the sample month to their survey vendor.
  4. Vendors will initiate surveys within three weeks after the sample month closes.
  5. Once a survey has been initiated it must be completed within six weeks.

The OAS CAHPS may be administered in conjunction with other surveys but sampling methods need to be followed to ensure patients are not overburdened by multiple surveys.

  1. For each sample month, the survey vendor must select the OAS CAHPS sample prior to selecting the samples for any other ASC survey.
  2. The ASCs cannot select the sample for any other facility survey they may choose to implement.
  3. The vendor must select the sample because the sample selection for OAS CAHPS cannot be disclosed to the facility.

OAS CAHPS Survey Implementation

  1. National voluntary implementation began in January 2016 with required participation scheduled to begin January 2018. CMS has proposed delaying implementation of the mandated 2018 date. The decision will be released in Medicare’s final 2018 ASC payment rule this November.
  2. It is unlikely the delay will be permanent because CAHPS surveys are already mandated in hospitals, home health, hospice, and dialysis centers.
  3. ASCs that have voluntarily participated in OAS CAHPS have received valuable information about the quality of outpatient care provided at their facility.

There are pros and cons to implementing the survey now versus waiting until CMS mandates the survey next year. It is often better to prepare early. What should administrators consider in determining what is best for their center?

Reasons to delay the OAS CAHPS Survey until 2018:

  1. Financial and administrative burden of submitting the data.
  2. Decision on the electronic survey mode option.

Reasons to implement the OAS CAHPS Survey now:

  1. You will know where your surgery center stands before mandatory reporting begins.
  2. You will have an opportunity to address identified issues for improved survey results.
  3. You can learn and understand your patients’ perceptions and make changes to increase overall satisfaction.
  4. Post-discharge surveying allows for a better assessment of the entire surgery process.

Peak One Surgery Center located in Frisco, Colorado has chosen to move forward with implementation of the OAS CAHPS survey now. It was an easy decision for us because it will allow us to get ahead of the competition. We can build out processes with our vendor and adjust our internal reporting systems. There will also be time for staff, physicians, and administration to learn the program. When my fellow administrators ask, I advise them to begin work with a vendor on voluntary implementation of the OAS CAHPS survey to avoid being at a disadvantage when the survey becomes mandatory.

Michaela Halcomb, Director of Operations

ASC Emergency Preparedness: Checklist for Compliance

ASC Emergency Preparedness: Checklist for Compliance

By ASC Governance, ASC Management, Leadership No Comments

Disasters come in many forms. They can be natural – a hurricane, tornado, flood, earthquake – or man-made – a chemical spill or cyberattack. While the impact of disasters varies greatly, what ultimately matters is how your ASC responds. An effective response, outlined in an ASC emergency preparedness plan, can protect and save lives, reduce facility damage, and make recovery easier.

Critical to such a response is the development of an ASC emergency preparedness program. I witnessed its value firsthand at a Colorado ASC that suffered a significant disaster in 2015. The ASC’s plan was instrumental in containing the damage, ensuring patients received the care they needed, and expediting repairs.

If your ASC is certified by Medicare, meeting emergency preparedness regulations is a requirement. Centers for Medicare & Medicaid Services (CMS) outlined these regulations in their final rule posted in September 2016. While the regulations went into effect in November 2016, providers and suppliers have until November 15, 2017 to comply with and implement them.

Earlier this year, Pinnacle III published a blog on “What the CMS Emergency Preparedness Rule Means for ASCs.” With the implementation deadline fast approaching, I thought it would be helpful to publish the ASC emergency preparedness program requirements below. They are organized for your convenience with the intent of helping you achieve and maintain compliance.

Your program must include, but is not limited to, the following four elements:

1. ASC Emergency Preparedness Plan

Develop and maintain an ASC emergency preparedness plan. The plan must:

  • Include a risk assessment. The plan should be based on a facility- and community-based risk assessment that employs an all-hazards approach. This approach focuses on capacities and capabilities critical to preparedness for a full spectrum of emergencies or disasters specific to the location of your ASC.
  • Factor in the types of hazards most likely to occur in your area. Take into consideration facility damage, care-related emergencies; equipment and power failures, and communication interruptions, including cyberattacks.
  • Include strategies for addressing emergency events identified in your risk assessment.
  • Address the needs of the patient population, including services your ASC can provide in an emergency.
  • Address continuity of operations, including delegation of authority and succession plans.
  • Include a process for cooperation and collaboration with emergency preparedness officials (e.g., local, regional, state, federal) in their efforts to maintain an integrated emergency response.
  • Include documentation of your ASC’s efforts to contact emergency preparedness officials and participate in collaborative, cooperative planning efforts.
  • Undergo a review and update at least annually.

2. Policies and Procedures

Develop and implement ASC emergency preparedness policies and procedures. Base them on the emergency plan and risk assessment discussed above and communication plan discussed below. Review and update policies and procedures at least annually. At a minimum, policies and procedures must address the following:

  • A system to track the location of on-duty staff and sheltered patients in your care during an emergency. Note: If you relocate on-duty staff or sheltered patients during an emergency, document the name and location of the receiving facility/location.
  • Safe evacuation from your ASC, including consideration of care and treatment needs of evacuees, staff responsibilities, transportation, identification of evacuation location(s), and primary and alternate means of communication with external sources of assistance.
  • Means to shelter in place patients, staff, and volunteers who remain in your ASC.
  • A system of medical documentation that preserves patient information, protects information confidentiality, and secures and maintains records availability.
  • Use of volunteers in an emergency and other staffing strategies, including the process and role for integration of state and federally designated health care professionals, to address surge needs.
  • Your ASC’s role in the provision of care and treatment as an alternate care site identified by emergency management officials, in the event of a waiver declared by the U.S. Health and Human Services Secretary.

3. Communication

Develop and maintain an ASC emergency preparedness communication plan. Review and update the communication plan at least annually. The plan must include the following seven components:

  • Names and contact information for staff, organizations providing services under arrangement, physicians, and volunteers.
  • Contact information for emergency preparedness staff (e.g., federal, state, regional, local) and other sources of assistance.
  • Primary and alternate means for communicating with your staff and emergency management agencies.
  • A method for sharing information and medical documentation for your patients with other providers to maintain continuity of care.
  • An appropriate means to release patient information in the event of an evacuation.
  • An appropriate means of providing information about the general condition and location of patients under your care.
  • A means of providing information about your ASC’s needs and its ability to provide assistance to the appropriate authority.

4. Training and Testing

Develop and maintain an ASC emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures, and the communication plan discussed above. Review and update the training and testing program at least annually.

With regard to training, your ASC must:

  • Provide initial training in emergency preparedness policies and procedures to all staff, individuals providing on-site services, and volunteers (consistent with their expected roles).
  • Provide emergency preparedness training at least annually.
  • Maintain documentation of all training.
  • Demonstrate staff knowledge of emergency procedures.

To meet the testing requirements, your ASC must conduct at least two exercises annually to test its emergency plan. You must:

  • Participate in a full-scale community-based exercise. If a community-based exercise is not accessible, participate in an individual, facility-based exercise. Note: If your ASC experiences a natural or man-made emergency requiring activation of your emergency plan, you are exempt from engaging in an exercise for one year following the onset of the event.
  • Conduct an additional facility-based exercise. This can be another individual, full-scale exercise or a tabletop exercise that includes a group discussion.
  • Analyze your response to and maintain documentation of all drills, tabletop exercises, and emergency events.
  • Identify and implement improvement opportunities, revising the emergency plan as needed.

Note: If your ASC is part of an integrated health care system with a unified and integrated emergency preparedness program, you may choose to participate in the system’s coordinated program. If you do so, there are additional requirements your ASC must meet. Review the CMS final rule to identify those requirements.

Quick Tips

To achieve compliance, follow the steps provided above. Some tips that will further assist you in your emergency preparation efforts are:

  • Designate an incident commander. This individual is responsible for the overall management of the emergency response.
  • Pre-assign other incident command roles. This could include a deputy incident commander whose responsibilities include filling the incident commander role in the event the incident commander is not on-site during the emergency. It could also include command staff (e.g., public information officer, safety officer, liaison officer) and general staff (e.g., operations, planning, logistics, finance/administration).
  • Make sure your ASC has the appropriate insurance and coverage for the emergencies and disasters you are likely to face.
  • If financial, patient, and other data is stored on-site, plan for how you will protect servers and other critical information technology.
  • Consider any “what ifs.” If there is something you think could happen during an emergency, plan for it.

Improving Your Emergency Preparedness Program

Development of an ASC emergency preparedness program can help a center achieve a more successful response to a disaster. But disasters are unpredictable. An ASC emergency preparedness program can only account for so much. That’s why it is critical to take advantage of every exercise to identify areas of your plan to revise and improve.

It’s also valuable to study how other health care providers responded to actual disasters. Doing so provides an opportunity to incorporate tried-and-tested processes and practices into your plan. In an upcoming blog, I will share many of the steps the Colorado ASC I mentioned took in response to its disaster. By doing so, I hope to help your ASC prepare for what you may face one day.

Diane Lampron, Director of Operations

Patient Registration Issues? Consider a Front Desk Audit

Patient Registration Issues? Consider a Front Desk Audit

By ASC Management, Revenue Cycle Management No Comments

Inaccurate patient registration can quickly derail a facility’s revenue cycle management efforts. Delayed reimbursement is costly. If your ambulatory surgery center is experiencing patient registration issues leading to lost or delayed reimbursements, consider conducting a front desk audit. Audit results often help identify training, communication, and process gaps that, once addressed, can get your center back on track.

When conducting your front desk audit, review how facility personnel collect the following items from patients:

  • Are scanned copies of patients’ insurance card(s) obtained and retained for future reference?
  • Does data entry in the patient registration sections of your patient accounting system match the scanned insurance card(s) on file? If not, what variances occurred?
  • Were the proper benefits eligibility and verification checks performed prior to the date of service?
    • Were eligibility and verification activities performed via a phone call or online?
    • If verified by phone, were the following elements – phone number, person spoken to, and reference number – recorded in patients’ accounts?
    • Were eligibility and verification details noted in patients’ accounts?
  • Were co-pay, deductible, and co-insurance details obtained and noted in patients’ accounts during the eligibility and verification process?
    • Were patients’ copays and deductibles collected on or before the date of service?
    • If not, were explanations recorded in patients’ accounts?
  • If required, were prior authorizations obtained before the date of service?
    • If not, was there information listed in patients’ accounts explaining why?

Recording audit results in a simple spreadsheet will provide you with an easy tool to assess your findings and identify trends.

Consider having staff members perform front desk audits on each other. Involving them in the assessment, education, and training aspects of patient registration auditing often yields lasting process improvements. Perhaps your ASC will realize the added benefit of a team inspired to collectively work towards an error free patient registration process.

Share this formula with them: Error free patient registration = clean claims = faster reimbursement = patient satisfaction = happy investors and staff. That’s a win-win for all involved!

Carol Ciluffo, VP of Revenue Cycle Management