Mitigating Surgical Risks in the Outpatient Setting

By Robert Hanscom, JD, Vice President of Business Analytics, Coverys
Outpatient surgeries account for half of all surgeries in the United States today, and offer innumerable benefits related to patient convenience, comfort, and cost savings. Ask someone who has been able to sleep in their own bed the night after a surgical procedure, and they may tell you they were glad to avoid the intrusive and sometimes expensive experience of being admitted to the hospital. They might also tell you that they thought their medical team and the patient services team were supportive and communicative, that their insurance covered a large portion of the bills, that scheduling their surgery was easy, and that they were able to go back to normal activities and work sooner than they expected.
At Coverys, we believe that data provides us with vital signals ― that a rise in a particular type of claims is a warning beacon that something needs to be done differently. Although outpatient surgery experiences fewer claims than inpatient surgery, it is critical that outpatient centers heed the signals from the inpatient setting to assess their vulnerabilities and make adjustments in the name of patient safety. Because what can go wrong in the inpatient setting can certainly go wrong in the outpatient environment as well.
Five Ways Outpatient Surgery Centers Can Be More Vigilant
A five-year analysis of Coverys surgical claims data suggests that some key vulnerabilities that are experienced frequently in the hospital setting are significantly better managed in the outpatient setting.
But how can outpatient surgery be even safer?
  1. Keep an eye on your culture. Many of the risks of surgery are cultural risks. They stem from the changeable and busy environment of hospital operating rooms, where there can be uncontrolled distractions ― like OR visitors (including equipment reps), cell phones, conversations, shift changes, and music ― and where staff and instrument set-ups can be ever-changing because of emergencies and unscheduled procedures. These types of cultural issues are likely deeply embedded contributors to many of the surgical claims, including allegations of retained foreign objects, which account for 8.52% of inpatient surgical claims and 5.08% of outpatient surgical claims.
  2. Focus on areas that lack formal procedures. Issues that lead to poor patient outcomes often stem from unclear leadership and loose processes. Determine what surgical processes could benefit from tighter procedures, like surgical tray set-up or counting of instruments and supplies at the end of a procedure, and focus on making incremental improvements. As for communication expectations and leadership roles, consider whether there are ways to refine your pre-surgical “huddle” process to ensure that everyone is properly briefed and expectations are clear.
  3. Not every outpatient surgery should end with the patient going home right away. Surgery doesn’t always go by the book. No matter the complexity of procedure, not everyone can, or should, go home after surgery. And because nearly 5% of outpatient surgical claims allege poor patient monitoring post-op, it stands to reason that some patients may need closer oversight after surgery. Don’t let your expectations or the economics of transferring a patient to hospital admission keep you from doing so.
  4. Give post-surgical instructions pre-surgically. Because so many adverse events happen after surgery, it is imperative that you manage the patient’s post-operative expectations before the day of the surgery. Focus carefully on informed consent and shared decision-making because a patient who believes they were not properly involved in the surgical decision is a patient more likely to allege malpractice later. When sending the patient home after surgery, speak with their caregiver about everything from bandage changes to pain management, as well as what to do if recovery does not go as expected.
  5. Adopt best practices, no matter how hard they are to implement. There are many kinds of processes, protocols, team communications training, or other efforts you can undertake to improve patient safety at your organization, and they vary in degree of difficulty and expense to implement. The surgical safety checklist developed and promoted by Dr. Atul Gawande and the World Health Organization is one of the most effective patient-safety tools ever developed. Yet, it has not been adopted by many hospitals and surgical centers despite the relative ease with which it can be implemented. Other efforts can take considerable work to undertake, but the benefits can be profound. Take a look at your own safety record and your available budget for training or new processes, and commit to some improvements for the coming year.
Outpatient departments and ambulatory surgery centers (ASCs) have done admirable work in balancing the dual aims of efficiency/convenience and patient safety. Our analysis across a five-year period of closed claims between 2011 and 2015 showed that just 30% of all surgical claims come from outpatient procedures, a trend that continues past 2016.

Still, it is important to remain vigilant ― doing our best work on behalf of patients, learning from our colleagues in outpatient and inpatient settings alike, and listening to the stories told by the claims data. Assuming that adverse outcomes are unlikely in the outpatient setting is a kind of confidence one should not allow oneself to have. Keep asking, “Do we have the same kinds of issues as are found in the inpatient setting? What are our vulnerabilities and how can we address them?” In the end, there are always ways to improve surgical safety ― to create better outcomes for your patients and to reduce malpractice claims too. Continue to learn from adverse events, patient complaints, and malpractice signal data. If you work in an outpatient setting, where safety results are strong, you should take cues from inpatient issues to help you identify potential vulnerabilities and prevent adverse outcomes. And if you work in an inpatient setting, where the challenges you face are great, you should look to the outpatient safety processes and practices to see what you can adapt to the realities of your environment. We believe that examining the claims data is a great place to start.
No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.

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