I recently came across a fascinating piece of journalism looking at how the U.S. airline industry made revolutionary improvements in airplane safety, virtually eliminating plane crashes after suffering a record death toll in 1996. Of course better technology helped. But a big part of the story was how the industry made many small improvements in risk management — especially in the way it empowered employees to report issues, from airplane mechanics to flight attendants. Regulators created an aviation safety reporting system that incentivized people to share their concerns in a confidential, non-punitive manner, meaning that employees were held harmless for innocent mistakes. This led to a flurry of changes, from better in-flight pilot teamwork to improved taxiway signage.

The healthcare industry followed suit, sort of. Many of us are familiar with the “time out” that now takes place in hospital operating rooms, where staff introduce themselves by name, confirm the nature of the procedure, and learn a bit about the patient lying on the table. Simple safety checklists were introduced, and they dramatically reduced surgical infection rates.¹ Hospitals also embraced confidential patient safety reporting systems (but, unlike the airline industry, they are still struggling to demonstrate a clear link to improved patient safety.²)

Still, it wasn’t until 2006 that Marty Makary M.D., M.P.H. — a surgeon and bestselling author — introduced the idea of a surgical safety checklist. The following year, Dr. Atul Gawande wrote a fabulous book called The Checklist Manifesto promoting the importance of using checklists in complex environments like hospitals.

The ambulatory surgery sector lags further behind the progress made by hospitals. This is especially true of the two-thirds of ambulatory surgery centers (ASCs) that are physician-owned and not associated with a hospital system.³ Of course, many procedures that take place in ASCs are short and simple, like lasik surgery and colonoscopies. But even these procedures carry risks. Moreover, I’ve assisted in plenty of long, complex surgeries in ASCs lasting eight hours or more. And ASCs are now gearing up to do technically challenging orthopedic surgeries like hip and knee replacements, which have historically been the exclusive domain of hospital operating rooms.⁴

ASCs have a long way to go in embracing a culture of patient safety, as they have not implemented the best practices above. Having worked in physician-owned ASCs for over years, I only participated in two pre-surgical “time outs” during my entire career. Nor do ASCs do before-and-after “counts,” to make sure that surgical sponges and instruments aren’t accidentally left inside body cavities (a safety innovation hospitals reluctantly implemented once insurers refused to reimburse them for correcting mistakes like these). In over twenty years working in same-day surgery centers, I only participated in a count like this maybe half a dozen times. In fact, when nurses rotated into my ASCs from hospital settings, then tried to enforce safety protocols like these, they were scoffed at and never invited back.

“If you mock a nurse once, or yell at them for bringing something up, they will never feel as comfortable voicing a concern to you again, and your patients will suffer.”

Marty Makary, M.D., M.P.H. and author of New York Times bestsellers Unaccountable and The Price We Pay

Moreover, I never encountered a confidential patient safety reporting system similar to the ones that hospitals have embraced. Especially in physician-owned ASCs, when something is amiss, operating room staff are reluctant to speak up, fearing retribution. This isn’t surprising. ASCs are much more intimate spaces than, say, aircraft assembly lines, and personal relationships matter a lot. Also, operating room staff are usually contractors that don’t enjoy employment protections of any kind.

Let me paint a clear picture of how this can jeopardize patient safety. Over the years, I assisted in many liposuction procedures where surgeons extracted much more than the amount fat that California regulations say can be safely removed in an outpatient setting. In every case, I warned these surgeons just before they hit their limit, and got nowhere. As these “cowboy surgeons” kept going, our nurses and anesthesia providers usually whispered together worriedly. But only an anesthesia provider has the power to force a surgeon to stop. And none did. The takeaway is that, if a surgeon takes risks, the patient asleep on the table might not have an empowered patient safety advocate in the room with them.

It’s imperative that all staff members in ASCs — nurses, surgical technologists, and anesthesia providers — receive regular training about their duties and obligations as patient safety advocates. Again, in all my years working in such centers, this never happened.

Just as importantly, agencies that accredit ASCs must be compelled by law to provide an easy way for operating room staff to confidentially register complaints about events that jeopardize patient safety. In the food service industry, county health departments require “see something, say something” placards with hotline phone numbers to be placed in every kitchen. Why not something similar in ASC operating rooms? Also, accreditation agencies must be obligated by law to make surprise spot checks of ASCs, just like in food service, especially after a confidential complaint is received. Unfortunately, these agencies only make site visits once every three years, and these are scheduled well in advance. Is it possible that the kitchen in your local Taco Bell is better surveilled than an operating room in an ASC?

Of course, the vast majority of ASCs are safe and well managed. Still, as I often counsel readers at the end of my posts, “trust but verify.”

Patients scheduled for surgery in ASCs are wise to take matters into their own hands. For advice on how to accomplish this, click over to my blog post about how to evaluate the ASC your surgeon wishes to use. In the meantime, in addition to your legislators, please contact the organizations below, asking them all to do a better job getting ASCs to adopt the commonsense patient safety practices described in this blog post.

U.S. Department of Health and Human Services, Office of Inspector General (link)

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) (link)

Accreditation Association for Ambulatory Health Care (AAAHC) (link)

Accreditation Commission for Health Care (ACHC) (link)

The Joint Commission (link)

Footnotes

¹ No Author (Fall 2008). A simple checklist that saves lives. Harvard School of Public Health. (link)

² Pronovost PJ, Morlock LL, Sexton JB, et al. Improving the Value of Patient Safety Reporting Systems. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK43621/ (link)

³ No Author. Ambulatory Surgery Centers: A Positive Trend in Health Care. Ambulatory Surgery Center Association. (link)

⁴ Sah, Alexander MD (host). (2022, 29 April). How the ASC Industry’s Growth is Improving the Surgical Process (episode 52) [Audio podcast episode]. In PSQH The Podcast. (link)

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