Only 7% of ambulatory areas accredited nationally
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The vast majority of physician offices and ambulatory centers — where an increasing array of invasive procedures is being performed — have virtually no accreditation oversight and little systemized tracking of infections and other adverse events, Healthcare Infection Prevention has learned. The Joint Commission on Accreditation of Healthcare Organizations is trying to address the gap with new standards and programs, but currently is only "in the foothills of these mountains," notes Robert Wise, MD, vice president for standards in the Joint Commission’s division of research. "One of the problems with these settings is that they have such minimal administrative infrastructure that we are not finding any data being collected systemically," he says.
"What you’re finding are the sentinel events that pop up in the newspaper. Most of this stuff is anecdotal. In these settings, there is no one collecting the data, there is no one aggregating the data, and there is no one saying these are the changes that we need," Wise adds.
The issue arose again recently when endoscopy clinicians warned that an increasing number of gastrointestinal procedures are being performed in physician’s offices and outpatient clinics without adequate assurance of appropriate infection control measures. They noted that federal reimbursement actually favors doing endoscopy in such settings, though the infection control oversight found in a hospital is often lacking. (See Hospital Infection Control, July 2002, under archives at www.HIConline.com.)
"The trend is that more and more kinds of [procedures] are leaving the hospital," Wise says. "And actually, we are now seeing a large percentage of doctors who are not even seeking hospital privileges anymore. It is becoming more common that doctors not even associate themselves with a hospital — [and with] what they view as the rigidity and bureaucracy of being part of a hospital."
Physician offices and ambulatory settings are eligible for Joint Commission accreditation, but thus far, only a small percentage has pursued the matter. A program launched in January 2001 aimed at office-based surgical practice has resulted thus far in some 60 accredited offices, says Michael Kulczycki, MBA, executive director of ambulatory accreditation.
In addition, the Joint Commission currently accredits some 1,300 ambulatory settings. While these facilities must meet Joint Commission standards for infection control and other areas, they remain a striking minority nationally. "The ambulatory care universe — ambulatory, not just office-based surgical practice — is 60,000 facilities," Kulczycki says. "And between us and other accreditation programs, the level of accredited organizations is 6% to 7%."
Hospitals have incentives to seek accreditation, he notes, including using the Joint Commission process to ensure Medicare certification. That is less of an issue in ambulatory care, so the primary drivers for accreditation are managed care contracts, local competition, and a desire for a quality seal of approval, he notes. "They want to demonstrate to their medical community and the patients that they serve that they focus on providing safe and quality care," Kulczycki says.
Anesthesia problems first to surface
The highest profile adverse events occurring in offices and ambulatory settings have centered on anesthesia and sedation problems, some which have resulted in patient deaths, Wise says. As the situation draws more attention, some states are starting to require accreditation from the Joint Commission or other organizations if the institution is going to be conducting anesthesia or moderate sedations, he says. "Those drivers’ are still very slow in growing," Wise says. "But because this problem still exists, we would expect more states and possibly the federal government to take a stance that accreditation is going to be required."
Infection control is not as prominent on the radar screen, but that may be a by-product of little surveillance and reporting. "To my knowledge, problems with infection control have not popped up," he adds. "But [there is] a difference between somebody having a cardiac arrest because of improper sedation and anesthesia vs. somebody having an infection that could take days to show up. And then they may not even return to the same practitioner.
"You have a much more difficult data collection problem. Clearly one of the areas of our interest is infection control. It takes a good amount of skill, surveillance, and the collection of data. It would be one of the areas that could become weak as these settings grow," Wise points out.
Rather than requiring ICP involvement — as is done in the hospital — the Joint Commission will make infection control a focus of the survey process, he says. "We would be expecting certain data collection, certain evidence of processes in place; all of those together would decide whether the current infection control program is sufficient."
The other major push for more oversight in the expanding continuum of care has been physician credentialing and privileging issues, he adds. "A license to practice medicine allows you to do anything [medically]," Wise says. "In a hospital setting, you have well-established processes to look at things such as privileging. It is almost unheard of, for instance, for a dermatologist to be doing liposuction in a hospital. They probably wouldn’t get the privileges to do that. It’s possible that they could, but there would be a lot more scrutiny. While in fact, pretty much anybody can do anything they want in the office-based setting," he adds.
(Editor’s note: Lest we paint with too broad a brush, it is important to remind that some same-day surgery centers are so proficient at infection control that they are focusing on areas usually associated with advanced hospital practice — eliminating rituals.)
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