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INFORMATION FROM ASA ON (1) JOINT COMMISSION REQUIREMENTS AND (2) ANESTHESIA INFORMATION MANAGMENT SYSTEMS
June 13, 2011
(1) Joint Commission/CMS Hospital Interpretive Guidelines
American Society of Anesthesiologists members have access to an up-to-date set of policy templates and implementation forms that will help their hospitals satisfy The Joint Commission’s requirements for anesthesia services. More precisely, the templates will be useful in ensuring compliance with Medicare’s Conditions of Participation for hospitals, which TJC has “deemed authority” to enforce. The Conditions of Participation themselves are broad principles made operational through the instructions to surveyors known as “Interpretive Guidelines.”
You may wish to consult the full text of the Interpretive Guidelines for anesthesia services and the January 14, 2011 Memorandum from CMS elaborating on some of the principles of the Interpretive Guidelines. They direct TJC, Medicaid and other hospital surveyors to check for the adoption of a number of policies and for specific content of certain records. TJC may add other requirements. Adoption and implementation of the requisite policies is the hospital’s responsibility, but the cooperation of the anesthesiologists is to everyone’s advantage.
An ASA ad hoc committee, chaired by Beverly K. Philip, MD, Professor of Anaesthesia at Harvard Medical School, and assisted by members of the Committee on Quality Management and Departmental Administration developed the templates for the required policies and records.
Note that these resources do not constitute legal advice and are not official ASA policy. They are, however, committee work products and should provide guidance in any necessary transitions as a result of last year’s modifications to the Interpretive Guidelines. They may be downloaded individually from www.asahq.org by ASA members.
1 - Introduction to the CMS Hospital COP Interpretive Guidelines
The introductory document highlights the affirmation by CMS of the principle that anesthesia and analgesia are on a single continuum. Some of the COP regulations apply only when “anesthesia” is administered. Each hospital, therefore, must establish policies and procedures, based on nationally recognized guidelines, that address whether specific clinical situations involve “anesthesia” or “analgesia.”
The Introduction also summarizes the committee’s templates and reminds anesthesiologists that they should take the initiative in working with their hospital’s Medical Executive Committee. All anesthesia departments and hospitals should review these templates, forms and resources with appropriate legal counsel and make their own determinations as to how to adapt them to their particular hospital setting, in compliance with federal and state laws and regulations.
2 - Scope of Anesthesia Services Policy
“Anesthesia services throughout the hospital (including all departments in all campuses and off-site locations where anesthesia services are provided) must be organized into one anesthesia service, under the direction of a qualified doctor of medicine (MD) or doctor of osteopathy (DO).” (COP Regulations §482.52)
The COP Interpretive Guidelines require anesthesia departments to address the circumstances under which an MD or DO who is not an anesthesiologist, a dentist, oral surgeon or podiatrist is permitted to administer anesthesia. Furthermore, the hospital must monitor quality and safety indicators for all anesthesia and analgesia services.
In states that have not opted out of the requirement of physician supervision of nurse anesthetists, medically-directing anesthesiologists are considered “immediately available” when needed by a CRNA under the anesthesiologist’s supervision only if he/she is physically located within the same area as the CRNA, e.g., in the same operative suite, or in the same labor and delivery unit, or in the same procedure suite, and not otherwise occupied in a way that prevents him/her from immediately conducting hands-on intervention, if needed.” (§482.52(a) and (c)). Remember that this is in the hospital regulations, and that the rules for billing medical direction are separate and distinct.
3 - Director of Anesthesia Services Policy
The Director of Anesthesia Services is responsible for “directing the administration of all anesthesia services, including anesthesia and analgesia, throughout the hospital (including all departments in all campuses and off-site locations where anesthesia services are provided).” (§482.52)
The Director’s responsibilities include evaluating the quality and appropriateness of the anesthesia patient care as part of the hospital’s QAPI (Quality Assessment / Performance Improvement) program. (§482.52).
The ASA materials contain additional requirements for the Director of Anesthesia service and present these in the form of a job description.
4 - Policies and Procedures Governing Anesthesia Privileging in Hospitals
The anesthesia service and its Director are responsible for planning, directing and supervising all activities of the anesthesia service. This responsibility includes establishing criteria for granting privileges to all providers, from topical/local anesthesia through all levels of sedation to general anesthesia.
ASA’s Policy Statements (1) Granting Privileges for Administration of Moderate Sedation to Practitioners who are not Anesthesia Professionals and (2) Granting Privileges to Non-Anesthesiologist Practitioners for Personally Administering Deep Sedation or Supervising Deep Sedation by Individuals Who Are Not Anesthesia Professionals, Statement on (2006) are incorporated in pertinent part in these Policies and Procedures Governing Anesthesia Privileging.
5 - Pre Anesthesia Evaluation Policy, Form and Note (Template)
Within 48 hours immediately prior to the delivery of the first dose of medication(s) for the purpose of inducing anesthesia, a qualified practitioner must perform a pre-anesthesia evaluation of the patient that includes, at a minimum,
- Review of the medical history, including anesthesia, drug and allergy history; and
- Interview, if possible given the patient’s condition, and examination of the patient.
The following may be performed within the 30 days before surgery, but they must be reviewed and updated as necessary within the 48-hour window:
- Notation of anesthesia risk according to established standards of practice (e.g., ASA classification of risk);
- Identification of potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure (e.g., difficult airway, ongoing infection, limited intravascular access);
- Additional pre-anesthesia data or information, if applicable and as required in accordance with standard practice prior to administering anesthesia (e.g., stress tests, additional specialist consultation);
- Development of the plan for the patient’s anesthesia care, including the type of medications for induction, maintenance and post-operative care and discussion with the patient (or patient’s representative) of the risks and benefits of the delivery of anesthesia. (§482.52(b)(1))
6 - Intraoperative Anesthesia Record Policy
The elements of the Intraoperative anesthesia record are so well established that there is no need to repeat them here. We will note, however, that a recent client question caused us to check up on whether the “operating practitioner” who supervises a CRNA who is not being medically directed must be identified in the anesthesia record. The answer is yes.
7- Post Anesthesia Evaluation Policy, Note and Form (template)
A postanesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia*, no later than 48 hours after surgery or a procedure requiring general, regional or monitored anesthesia services. (§482.52(b)(3)). The qualified professional performing the postanesthesia evaluation need not be the same individual who administered the anesthetic.
For inpatients: the postanesthesia evaluation must be completed within 48 hours from the time the patient is moved to PACU, ICU or other designated recovery area. The evaluation should not occur until the patient has sufficiently recovered from the acute effects of the administered anesthetic, to allow the patient’s participation (e.g., answer questions appropriately, perform simple tasks, etc.) and to adequately assess the essential elements of the evaluation. If the patient is unable to participate in the postanesthesia evaluation, the reasons for the non-participation and expectations for recovery should be documented.
For outpatients: if permitted by State law and hospital policy, the evaluation may be completed after the patient is discharged, provided this occurs within the 48-hour timeframe. As a practical matter, however, it will rarely, if ever, be possible to assess elements such as respiratory function, or hydration status in a patient who has gone home.
The elements of an adequate post-anesthesia evaluation should be clearly documented and include the assessment of stability or satisfactory control of:
- Respiratory function, including respiratory rate, airway patency, and oxygen saturation;
- Cardiovascular function, including pulse rate and blood pressure;
- Mental status;
- Nausea and vomiting; and
- Postoperative hydration. (§482.52(b)(3))
The above is a summary only. If one of the numbered policies looks as though it may contain answers to your questions, or if it suggests that your department’s policies may need updating, we encourage you to obtain the full policy and any associated notes and templates from ASA. We also stress, as does ASA, that neither the policies nor the summaries here contain legal advice. In case of questions, you should consult with your Medical Executive Committee and also with hospital counsel, as appropriate.
(2) ASA Committee on Information Management White Paper
Another ASA committee, the Committee on Information Management chaired by Armin Schubert, MD, MBA of the Ochsner Clinic in New Orleans, has recently released a white paper on Anesthesia Information Management Systems (AIMS). This white paper is an introduction to rules of the road for AIMS. It may serve as the foundation for the data-based decision-making that drives quality improvement, better outcomes, greater efficiency, science-based practice guidelines, public policy, and cost containment.
The stated purpose of the resource, “AIMS and Sharing Your Patient Data – A Resource for Potential Users,” is to: “Provide an authoritative, easily accessible resource to assist ASA members and others with the selection and implementation of an AIMS capable of sharing data with reputable national electronic data warehouses.”
The separate sections of the white paper can be downloaded from the Anesthesia Quality Institute (AQI) website by title, below:
Topics covered include How to select/buy AIMS for optimal data sharing; Interoperability; Decision support, Quality metrics, Meaningful use and Data sharing – within your institution, with national repositories, benefits and pitfalls.
In case you don’t already realize the extent and the value of the practice administration information that ASA develops and publishes, we hope that the synopses above will illustrate the point and lead you to the resources that you need.
One of ASA’s unique and important contributions to the anesthesia practice management information pool is its annual survey and report on fees paid by commercial (non-governmental) health insurers. The new cycle has just begun, and we hope that you will participate.
2011 ASA Commercial Fee Survey – Please Complete by July 3rd
ASA has just launched its latest survey of commercial payment rates, and we join them in urging your groups to participate. The survey results are highly valuable to practices seeking to benchmark their commercial conversion factors (although some groups inevitably find that the statistics are either too high or too low to be useful in their own contract negotiations.) You may see the two reports from last year’s survey in the October 2010 and January 2011 issues of the ASA Newsletter.
From the introduction to the survey, which you will find at http://www.surveymonkey.com/s/38HNVHD :
The American Society of Anesthesiologists invites you to participate in our ninth survey of commercial payment rates. As with previous surveys, we will publish the results in the ASA NEWSLETTER later this year. We would greatly appreciate your help with this update. As a reminder, the Statements of Antitrust Enforcement Policy in Health issued jointly by the Department of Justice and the Federal Trade Administration make it possible for us to gather this information as long as certain conditions are met. The most important condition, besides only publishing aggregate statistics, is that the data you provide be AT LEAST THREE MONTHS OLD.
Please provide the following information for your five (5) highest-volume commercial payers (not Medicare, Medicaid, other government payers) based on volume of services provided on an annual basis. If you have fewer than five contracted commercial payers, please enter information for all of your commercial payers. AGAIN, PLEASE ENSURE YOUR DATA IS AT LEAST THREE MONTHS OLD.
TO OUR ANESTHESIOLOGISTS: Please ask your practice manager or billing service to complete this questionnaire. It is important that we receive only one response from each anesthesia group. We ask that you or your staff complete the survey NO LATER THAN JULY 3, 2011.
Thank you for your participation!
We at ABC also thank you.
With best wishes,
President and CEO