THE WEEK OF JANUARY 9, 2023

NJAASC JANUARY GENERAL MEMBERSHIP MEETING

Wednesday, January 25, 2023

8am-2:00pm

Galloping Hill Golf Course

3 Golf Drive Kenilworth, NJ

"Getting Down to Business:

The Business Aspects of Running Your ASC”

We'll cover the LEGAL, HR, Billing KPIs and Regulatory Compliance aspects of running an ASC in today's environment to help you succeed.

Doors open at 8am for registration.

Content begins at 9am.

Come early and visit our vendors.

There will be over three dozen in attendance and displaying.

This is a great opportunity to network, renew old acquaintances and make new friends!

Member Centers register your employees to attend for Free.

Vendor Members attend for Free, as well as participate in the Vendor Exhibit! Attendees can visit the booths, participate in the prize giveaways, demonstrations, chat, view products and services!

Don’t miss the PRIZES! Besides the vendor givea-ways, NJAASC is offering prizes to all registered ASC attendees! Visit the vendor booths to be automatically enrolled in the Grand Prize Drawing!

IT’S TIME TO RENEW YOUR NJAASC MEMBERSHIP!

Please be aware that 2023 NJAASC dues renewal letters have gone out to the membership. Your 2022 membership runs out January 2023, so make sure you renew in order to attend the events we have scheduled for 2023, including:

January 25, 2023 - Quarterly Membership Meeting - Galloping Hills Country Club in Kenilworth, NJ: ONLY FOR NJAASC CENTER AND VENDOR MEMBERS.

February 15, 2023 - Infection Control Conference, in cooperation with NJDOH - Galloping Hills Country Club in Kenilworth, NJ: ONLY FOR NJAASC CENTER AND VENDOR MEMBERS

NJAASC would like to thank all of you for your support this past year. As you can see, we have even bigger plans for 2023, including the 13th Annual ASC Conference, April 18 & 19, 2023.

VENDORS

Your renewal invoice includes an option to ‘lock in’ your discounted table for the 13th Annual ASC Conference.

It is optional, but this offer is only extended in conjunction with your 2023 dues renewal.

If you have any questions about your membership renewal or have not received an invoice, please contact Kelly Biddle: kbiddle@njpsi.com

NJAASC WOULD LIKE TO WELCOME

OUR NEWEST MEMBERS

Centers:

Oak Tree Surgery Center, Edison, NJ

Bergen Surgery Center, Paramus, NJ

Center for Advanced Surgical Excellence, Voorhees, NJ

Vendor Member:

Advanced Sterilization Products

Associate Members:

Align Healthcare Real Estate

LJM Surgical, LLC

WELCOME ABOARD!

New Jersey Law Protecting Healthcare Workers During Ownership Change of Control

Senate Bill 315 , the new law that protects healthcare workers during ownership changes of control, went into effect on November 16, 2022. Under the law, non-governmental health care entities must offer continued employment to all eligible employees, to the extent the number of available

employment positions is not less than the total number of eligible employees, for at least four months without any reduction in wages, paid time off, or the total value of their benefits – including health care, retirement, and education benefits --, following a change in control

of a health care entity, defined as any sale, assignment, transfer, contribution or other disposition of a health care entity’s assets or controlling interest, including by consolidation, merger, or reorganization. Eligible employees include all individuals employed within the 90-day period immediately preceding the change in control, with the exception of managerial employees and any person discharged for cause by the former employer the during that 90-day period.

During the four-month transitional period, the successor health care entity employer must offer available employment positions in writing to eligible employees who previously held those positions until the available employment positions are filled or until no more eligible employees are available. The offer of employment must remain open for at least ten business days from the date of the offer. In the event that the number of available employment positions is less than the total number of eligible employees, then employment must be based on seniority and experience. An employee who is retained pursuant to the new law cannot be terminated without cause during the transitional period, unless the termination is a result of downsizing, in which case employees with the most seniority or experience have priority over the other employees. Further, laid off employees must be offered any positions they held if they are subsequently restored during the transitional period. After the transitional period, the successor employer must evaluate all retained employees and offer to continue to retain them if their performance during the transitional period was satisfactory.

Health care entities subject to the new law include general and special hospitals, ambulatory surgical centers, ambulatory care facilities, licensed imaging centers, mental hospitals, public health centers, diagnostic enters, treatment centers, rehabilitation centers, extended care facilities, skilled nursing homes, nursing homes, intermediate care facilities,

outpatient clinics, dispensaries, home health care agencies, and residential health care facilities. Private practices and governmental health care entities are not subject to the new law.

John D. Fanburg, Esq.

Brach Eichler

jfangurg@bracheichler.com

HIPAA TIP

HIPAA ORGANIZATIONS AND TERMS

Understanding the HIPAA Rule and HIPAA compliance starts with knowing the organizations that support HIPAA and basic terminology associated with HIPAA. Below is a list of important terms and organizations that are relevant and very helpful when educating oneself on HIPAA compliance.

• PHI: Protected Health Information, also referred to as personal health information, is all the medical data a healthcare professional collects to identify an individual and determine their appropriate care.
  
• ePHI: Stands for electronic Protected Health Information and can be any identifiable patient information that is produced, saved, transferred, or received in an electronic form.
  
• Breach: Is a security violation in which sensitive, protected or confidential data (PHI/ePHI) is copied, transmitted, viewed, altered, or stolen and used by an individual unauthorized to do so.
  
• HHS: The Department of Health and Human Services is responsible for creating HIPAA and protecting the health of all Americans by providing essential human services.
  
• OCR: The Office for Civil Rights is responsible for enforcing HIPAA regulations and standards.
  
• CMS: The government agency within HHS is the Centers for Medicare and Medicaid services, administering major health programs in the U.S.
  
• Office of the National Coordinator: Is a staff division of the Office of the Secretary within HHS. ONC leads national health IT efforts and is charged as the principal federal entity to coordinate nationwide efforts for advancing information technology and electronic exchange of health information.
  

Section 405(d): Came about from the Cyber Security Act of 2015 to raise awareness, provide vetted cybersecurity practices, and move towards consistency in mitigating current pertinent cybersecurity threats to the healthcare sector.

Learning more about HIPAA, its terms and organizations will assist you and your staff with staying HIPAA compliant.

Dawn Meglino

HIPAA Compliance Specialist, CHPSE, CCSA, CCAP

dawn.meglino@anatomyit.com

Addressing Key Deficiencies in ASCs

Six key areas were identified as deficient by the Accreditation Association for Ambulatory Health Care (AAAHC) during on-site surveys of more than 1,000 ASCs during January 2021 through March of 2022 (AAAHC, 2022). The standards ranked highest as deficient are:

• Emergency Preparedness (27%)
  
• Documentation (21%)
  
• Credentialing, privileging, and peer review (20%)
  
• Quality of care (19%)
  
• Infection Prevention/Safe Injection Practices (19%)
  
• Quality Improvement (17%)
  

Regardless of the regulatory or accreditation organization performing your survey, all examiners evaluate these critical elements during on-site reviews. The key areas that continue to be trending concerns in healthcare are opportunities for closely examining if and how your ASC is meeting these standards. There are approaches to help you assess these and other areas for compliance.

1. Review the requirements for each standard in the most current standards manuals and document evidence of how your ASC is meeting the requirements.
   
2. Confirm that there are policies in place that describe the processes for these areas.
   
3. Perform an annual review of your Quality Management Plan.
   
4. Educate your staff and physicians.
   
5. Involve peers, administrators, and physicians.
   
6. Perform an Emergency Preparedness Exercise.
   
7. Determine Quality Improvement (QI) studies that include data analytics to provide evidence of compliance and corrective actions where needed. A few QI study suggestions pertinent to the key deficiencies are Medical Record Audits, Physician Documentation Audits, Allergy documentation, Hand Hygiene Practices, Safe Injection Practices, Endoscope reprocessing, Safe OR Hand-Off. Take a fresh approach – do you have a thought for a QI study specific for your center?
   

With 2023 looming upon us, now is a great time to begin your review processes. In my clinical and professional experiences, plans that are continually reviewed, understood, kept up-to-date, and have total center buy-in, are the best preparations for surveys and successful outcomes.

Most importantly, your plans can assure the provision of safe and quality care to your patients.

Happy Holidays and best wishes for a Prosperous, Safe, and Healthy New Year.

Claire Cerame, MSN, RN

Positive Outcomes QAPI Consulting, LLC

ccerame@PositiveOutcomesQI.com

From centers:

Fire rated doors must have fire rated glass if there is a glass panel in them.

Make sure your governing body approves a list of contracted vendors annually.

Performance Improvement Opportunities in Medication Management.

I often get asked if I can recommend performance improvement studies that could be implemented that look at medication management activities at the surgery center. There are numerous opportunities to study drug usage.

Tracking drug safety, drug security and drug management at the ASC is important for many reasons. Completing these audits validates your process as being effective or not. One simple and important study is to look at post-op nausea and vomiting and the incidence occurring at your center. Data has shown that customer satisfaction surveys suffer when patients experience nausea and/or vomiting; therefore, identifying your current rate of nausea and/or vomiting is important and it’s easy to accomplish.

• Simply place a notebook or blank sheet in PACU and ask the nurses to place a patient sticker on the Notebook whenever they give a Medication to a patient for nausea or vomiting.
• At the end of the month count the number of stickers vs. number of surgeries that month.
• This gives you the incidence.
• Complete this for 3 months.
• If you are over 15% you may want to identify reasons.
• JDJ Consulting has developed a tool that can allow you to dig deeper into causes of PONV.

Determining your corrective action is quite simple and important

JDJ Consulting, LLC.

Lesley@jdjconsulting.net

Q: Do we have to pay an additional fee to an attorney to arbitrate NJ PIP cases?

A: Let me put it to you this way: you should not and if an attorney wants additional payment from you, find another attorney!

Arbitration in NJ pays attorney legal fees, comfortably. NY is a different story; reimbursement for legal fees is putrid, so for NY cases you will undoubtedly have to kick in a percentage to the attorney.

Q: Recently we had an incident with a patient transfer, where a patient was not roused……… Since patient was transferred from an ASC to a hospital (higher level of care), is it a reportable event?

(I have deleted the rest of this question as it is not relevant.)

A: Absolutely. If you ever have a question of what is and what is not, contact:

Acute Care Program: 800-792-9770

Stefanie Mozgai from NJDOH

Q:    Do laser eye laser procedures done in an ASC require any type of medical clearance or just an Opth. H&P?

A: It is an ASC procedure so you would need an H&P of some kind, according to your policy & procedures.

TELEHEALTH: THE NEW NORMAL IN HEALTHCARE CAREERS

Telehealth has become the new normal in healthcare careers. With the outbreak of the COVID-19 pandemic, many healthcare facilities have had to close their doors to in-person visits.

This has left many people in need of healthcare services without access to their usual providers. Telehealth has been a lifesaver for many people in these situations. It allows people to receive the care they need from the comfort and safety of their own homes.

Telehealth careers are expected to grow exponentially in the coming years. This is due to the increasing demand for remote healthcare services. Telehealth provides a convenient and safe alternative to in-person visits.

Telehealth careers offer a variety of opportunities for those interested in the field. From providing remote patient care to developing new telehealth technologies, there is a place for everyone in the telehealth field.

Keith McConomy

Mitchell Martin Healthcare Inc.

kmcconomy@hcmmi.com

Managing vendor relationship strategies in the healthcare industry can lead to mutually beneficial relationships both in the long and short term. 

It can be a process and might not get where you want to be overnight, but it’s worth the effort. A few beneficial points of view for looking at this relationship are:

Mutual Education

Collaborative Consulting

Clear Boundaries and Expectations

Jillian Dickerson

HYBRENT

hello@hybrent.com

To identify revenue cycle shortcomings, monitor key performance indicators (KPIs) and compare your performance against benchmarks. One KPI worth tracking is AR greater than 90 days. The total AR percentage over 90 days should be below 15% of AR. When an ASC’s AR percentage over 90 days exceeds 15%, this indicates the likelihood of revenue cycle problems, especially when the percentage greatly exceeds a center’s norm. Analyzing this metric by financial class will help narrow down issues.

Karena McKenzie

Surgical Notes

Karena.mckenzie@surgicalnotes.com

Your managed care contract negotiation specialist should regularly contact your payers, and not just when you require assistance with resolving claims issues or to engage in contract renegotiations. Periodically touch base to see if there is anything else your ASC can do to streamline the claims submission and payment processes. Also, inform payers of specialty and/or procedure expansion plans to give them time to begin preparations for negotiations concerning contract adjustments. While they may not say it, payer representatives should appreciate your willingness to help them, and their team do their jobs in a more efficient and effective manner.

Kathryn Boylan

SISFirst

kboylan@sisfirst.com

Essential Steps for Flexible Endoscope Reprocessing

To ensure flexible endoscopes are safe for patient use, all staff involved in reprocessing this equipment must understand and consistently follow a number of steps which have been distilled down to seven essential steps. Ensuring adherence to these steps requires a complete and effective reprocessing program. These recommendations apply to all settings where endoscopic procedures are performed and where endoscopes are reprocessed.

1. Pre-Cleaning: Pre-Clean flexible endoscopes and reusable accessories by following the device manufacturer’s instructions for use (IFU). Perform pre-cleaning immediately following completion of the endoscope procedure to help prevent the formation of biofilm.
   
2. Leak-Testing: For endoscopes that require leak testing, perform the leak test using manufacturer’s IFU after each use and prior to manual cleaning. Leak testing detects damage to the external surfaces and internal channels of the endoscope that can lead to inadequate disinfection and further damage of the endoscope.
   
3. Manual Cleaning: Perform meticulous manual cleaning including brushing and flushing channels and ports consistent with the manufacturer’s IFU before performing high-level disinfection (HLD) or sterilization. Perform manual cleaning within the timeframe specified in the manufacturer’s IFU. Manual cleaning is the most critical step in the disinfection process since residual organic material can reduce the effectiveness of HLD and sterilization.
   
4. Visual Inspection: After manual cleaning, visually inspect the endoscope and its accessories. Visual inspection provides additional assurance that the endoscope and its accessories are clean and free of defects. Complex devices such as flexible endoscopes may require the use of lighted magnification or additional methods to assist with the inspection process.
   
5. Disinfection or Sterilization: Following cleaning and visual inspection perform HLD or sterilization in accordance with the manufacturer’s IFU. Carefully review and adhere to the endoscope manufacturer’s reprocessing instructions and to the IFU for chemicals or sterilants and any equipment (e.g., automated endoscope reprocessors) used for reprocessing to help ensure that effective disinfection occurs.
   
6. Storage: After reprocessing is complete, store endoscopes and accessories in a manner that prevents recontamination, protects the equipment from damage, and promotes drying. Store processed flexible endoscopes in a cabinet that is either:
   

i. of sufficient height, width, and depth to allow flexible endoscopes to hang vertically without coiling and without touching the bottom of the cabinet OR

ii. designed and intended by the manufacturer for horizontal storage of flexible endoscopes.

Documentation

Maintain documentation of adherence to these essential steps each time an endoscope is reprocessed. Documentation is essential for quality assurance purposes and for patient tracing in the event a look back is necessary.

Nancy Chobin, RN, AAS, CSPM, CFER

nancy@spdceus.com

414 River View Plaza Trenton, N.J. 08611 •  (609) 503-7696  • info@njaasc.org

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