7 Steps to Better Quality Control at Orthopedics & Spine Surgery Centers

Karen Reiter on infection controlDiagnostic and Interventional Surgical Center, the ambulatory surgery center arm of  DISC Sports & Spine Center in Marina del Rey, Calif., has done over 7,000 cases since it opened its doors in 2006 and reported a zero surgical site infection rate during that time.

"Patients should be able to leave without an infection and have a great experience," says Karen Reiter, administrator at both Diagnostic and Interventional Surgical Center and DISC Surgery Center at Newport Beach.

Ms. Reiter discusses seven steps to better quality control at orthopedic and spine surgery centers.

1. Limit the risk upfront.
The surgeons and staff at DISC work hard to keep the risk to a minimum, and have been very successful by implementing several protocols. As a routine part of pre-op, we ask all scheduled patients if they have had exposure to MRSA or a history of a skin infection that was difficult to heal. It is surprising how many patients (athletes and non-athletes alike) say they do. When appropriate, the staff also do a preoperative baseline screening. If patients test positive, they are encouraged to see their internist or an infection control specialist for preoperative treatment, and none of their patients have denied this treatment.

"Much of our care and staffing are directed to avoid cross-contamination, and prevent infection. In the environment of the Surgical Center, we can significantly limit the contacts of the patient," says Ms. Reiter.  "At a hospital, on the other hand, there are multiple contacts through admissions, preoperative surgery and postoperative floor, as well as all the ancillary services. At our center, a patient is admitted to a room, the preoperative admitting nurse is usually the same nurse that cares for the patient after the procedure, and contacts are significantly limited. This dramatically lowers the rate of cross-contamination, as essentially every patient is treated in an isolated fashion."

DISC is an official medical services provider for the U.S. Olympic Team, Red Bull's North American athletes and the Los Angeles Kings.

2. Emphasize hand washing for everyone on the same level.
DISC emphasizes the importance of hand washing from the medical director down to the newest employee; everyone is responsible for following the hand washing policy and speaking up when they see someone else who hasn't.

“We embrace a 'don't be afraid to speak up' culture. At our surgery center, it's not that the surgeon is the leader and everyone else is underneath," says Ms. Reiter. "It's a collaborative environment. In some cases, physicians may not be aware of the right hand washing techniques. They know to wash between patients, but they don't know that touching a patient's chart is the same as touching the patient, and they need to wash again."

Ms. Reiter has an anonymous person do a "hand washing blitz" to watch whether everyone is washing their hands appropriately. "At first people didn't like this, but now they accept it," says Ms. Reiter. "It helps when the medical director or predominant users of the facility are also supportive of the 'I just noticed you missed a great hand washing opportunity' discussion."

3. Install an advanced air purifying system. Infections can travel as easily through the air as they do on our clothes from one room to the next. DISC has installed an air purifying system so that air from each room goes through a filter to be cleaned constantly and isolated from the rest of the building.

"This is something unique to the DISC facility," says Ms. Reiter. The surgery center installed a $950,000 environmental air conditioning system that provides a HEPA and UVC filtered air to all areas, including preoperative recovery and patient waiting. Each operating room has individual units keeping high volumes of air flowing through the HEPA filter and high-intensity UVC emitters to eliminate airborne germs, bacteria and microorganisms.

4. Enhance patient education on wound care.
An important part of the patient's experience extends beyond their time at the surgery center to taking care of the surgical site once they've returned home. There are steps they can take to avoid infecting the surgical site when they are changing wound dressings, and it's important for each patient and family member to understand this process.

"Surgery centers should do a good job with patient and family education in terms of wound care," says Ms. Reiter. "We, as an ASC, send patients home with wound care supplies, so they are able to cover their wounds during a shower and understand how to do the dressing. We want them to be able to take care of it."

5. Adhere to strict surgical attire policies.
DISC has strict policies about its surgical attire. For instance, no surgeon or employee is allowed to wear their scrubs outside of the facility. If the staff leaves for lunch, they must change out of their scrubs. While in the center, no personal garments may hang out from underneath the scrubs. Masks must be worn correctly, and cloth hats are not allowed in the facility without a cap on top of them.

"You need a strong buy-in from physician owners and medical directors on this," says Ms. Reiter. "Staff members will do what they are told, but physicians need other physicians to police them."

6. Conduct bladder scanning.
One of DISC's policies is to conduct bladder scans on all patients, both preoperatively and post-operatively, to make sure the bladder is working properly. The center also encourages early discontinuation of catheters and use of medications to enhance voiding and reducing residual urine, which is essential to preventing urinary tract infections.

"One of the ongoing quality assurance studies we are now conducting involves looking at how post-operative voiding can impact readmission or risk of infection," says Ms. Reiter.  

7. Embark on performance and quality-improvement measures.
Every facility can work on programs to improve quality of performance. These are going to be important as carriers begin pay-for-performance instead of necessarily fee-for-service reimbursement models. DISC conducts improvement meetings, quality-assurance protocols and ongoing studies to benchmark against national standards.

"Our quality-improvement meetings — like staff meetings — include everyone. We go around the room to see what others are doing differently," says Ms. Reiter. "This openness helps find best practices. We are also running a lot of quality-improvement projects, and have compared our measures to those the hospitals have to follow to verify we are meeting and exceeding them."

Ms. Reiter recommends surgery centers aggressively research hospital-quality measures and published benchmarking data and make sure their numbers exceed them. The ability to report these numbers to potential patients will help attract them and drive patient volume in the future.

"It is our goal to deliver a high-quality product that exceeds all national standards, while still providing a personal environment and a great experience for our patients," says Ms. Reiter.

More Articles on Patient Safety:

Tennessee's Le Bonheur East Surgery Center Evacuated Due to Gas Leak

Adopting Electronic Hand Hygiene Monitoring Systems to Boost Patient Safety

Study: Errors in Post-Surgical Care Are Common

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