CMS' safe surgery checklist measure and the Universal Protocol

August 1, 2012— The Centers for Medicare & Medicaid Services (CMS) is implementing a new quality reporting program for ambulatory surgery centers that introduces a CMS structural measure on the use of a safe surgery checklist (ASC-6); the same measure will also be adopted for outpatients in hospitals. Beginning in 2013, ambulatory surgery centers and hospitals (for outpatients) would report a yes or no response regarding their organization’s use of a safe surgery checklist during 2012. This information would be submitted via a CMS-designated website annually thereafter. The use of a checklist creates an expectation that organizations assess effective communication and safe practices during three perioperative periods:

1. Prior to administration of anesthesia;
2. Prior to skin incision;
3. Prior to the patient leaving the operating room or procedural area.

For payment determination purposes, the measure will be applied to ambulatory surgery centers for the calendar year 2015 and for the Hospital Outpatient Quality Reporting Program as OP-25 for calendar year 2014. The measure has been proposed for the Hospital Inpatient Quality Reporting Program for fiscal year 2016 and beyond (the final rule is anticipated to be issued in early August).

Questions have arisen about how The Joint Commission’s Universal Protocol (UP) can be used to meet this structural measure. CMS does not require the use of a specific checklist, and provides examples of checklists that can be used. The World Health Organization (WHO) and The Joint Commission are specifically cited as resources. The UP focuses on wrong person, wrong procedure, and wrong site surgery, and includes issues that are addressed in many safe surgery checklists. Since the UP was published, checklists have been developed that contain additional practices supporting safe surgery, such as assessment of the patient’s risk of blood loss in terms of the units of blood available.