Quality Report

ASC Quality Collaboration Quality Report

Third Quarter 2023

During 2020, the ASC Quality Collaboration developed a new data platform for the collection and reporting of ambulatory surgical center (ASC) quality data. That new platform was used throughout 2021 to compile benchmarking data. Starting with First Quarter 2022, the most recent four quarters of data are included in this report, along with the 2022 annual (Q1 through Q4 2022) rate for each measure.

It should be noted that two measures have been retired from this report since the 2019 quality data was posted. These two measures are Prophylactic IV Antibiotic Timing and Appropriate Surgical Site Hair Removal. As a result, data for these two measures is no longer included in the quality report. However, the specifications for those two measures are still included in the Implementation Guide.

This public report has been made possible through the voluntary efforts of participants in the ASC Quality Collaboration. The Third Quarter 2023 data was collected from 2,073 ASCs. The following organizations agreed to collect and submit clinical quality data reflecting patient admissions* from July 01 through September 30:

  • Ambulatory Surgery Center Association;
  • AMSURG;
  • California Ambulatory Surgery Association;
  • Covenant Physician Partners;
  • HCA Ambulatory Surgery Division;
  • Proliance Surgeons;
  • Regent Surgical Health;
  • SCA Health;
  • Surgery Partners;
  • United Surgical Partners International (USPI);
  • NVision Eye Centers;
  • NueHealth;
  • Sovereign Healthcare;
  • Visionary Enterprises, Inc

This report presents aggregated performance data for the following ASC facility-level quality measures developed by the ASC Quality Collaboration:

  • Patient Fall in the ASC
  • Patient Burn
  • All Cause Hospital Transfer/Admission
  • Wrong Site, Side, Patient, Procedure, Implant
  • Normothermia
  • Unplanned Anterior Vitrectomy
  • Toxic Anterior Segment Syndrome (TASS)
  • All Cause Emergency Department Visit Within One Day of Discharge
  • All Cause Unplanned Hospital Admission Within One Day of Discharge

This data and the accompanying information do not present all there is to know about the quality of ASCs. Patients are encouraged to discuss these quality indicators with their local ASC staff and their physician.

The data presented here has been self-reported by participating organizations and has not been independently validated by the ASC Quality Collaboration.

Questions or comments regarding this report may be directed to Kathy Wilson, Executive Director, ASC Quality Collaboration at kathy.wilson@ascquality.org.

Patient Fall in the ASC

Falls are an important issue for patients having outpatient procedures or surgery because virtually all patients receive sedatives, anesthetics and/or pain medications as a routine part of their care. The use of these medications increases the likelihood of a fall.

The frequency of ASC admissions experiencing a fall while in the confines of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.

2023Q3 Rate of Patient Falls

0.126 per 1000 admissions

Represents 2,586,281 ASC admissions seen at 2,069 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: Patient Fall in the ASC


generated graph for metric by quarter

Patient Burn

Burns are an important issue for patients having outpatient procedures or surgery because the equipment and supplies routinely used in providing these types of services can increase the risk that a patient will experience an unintended burn.

The frequency of ASC admissions experiencing a burn, regardless of severity, while in the care of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.

2023Q3 Rate of Patient Burns

0.017 per 1000 admissions

Represents 2,586,104 patient admissions seen at 2,068 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: Patient Burn


generated graph for metric by quarter

All Cause Hospital Transfer/Admission

ASCs provide surgical services to patients not requiring hospitalization. Therefore, ASCs screen patients referred to their facilities to ensure they can be safely cared for as an outpatient.

The frequency of ASC admissions experiencing a transfer or admission to a hospital upon discharge from participating ASCs is shown below as a rate per 1000 admissions. Not all conditions requiring a hospital transfer or admission result from the care the patient received in the ASC, nor can all medical conditions requiring a hospital transfer or admission be anticipated in advance. Therefore, some level of hospital transfer or admission is expected.

2023Q3 Rate of Hospital Transfers/Admissions

0.807 per 1000 admissions

Represents 2,588,854 patient admissions seen at 2,073 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: All Cause Hospital Transfer/Admission


generated graph for metric by quarter

Wrong Site, Side, Patient, Procedure, Implant

Wrong site, wrong side, wrong patient, wrong procedure and wrong implant events are a concern for patients having outpatient procedures or surgery. There are steps that can be taken to help prevent errors such as surgery performed on the wrong part of the body or the wrong side of the body.

The frequency of ASC admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event while in the care of participating ASCs is shown below as a rate per 1000 admissions. Lower rates are better.

2023Q3 Rate of Wrong Site, Side, Patient, Procedure, Implant Events

0.024 per 1000 admissions

Represents 2,586,281 patient admissions seen at 2,069 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: Wrong Site, Side, Patient, Procedure, Implant


generated graph for metric by quarter

Normothermia

Maintaining body temperature within a normal range (normothermia) is important in patients who have general, spinal or epidural anesthesia lasting 60 minutes or more. Normothermia helps reduce the risk of surgical complications, including the risk of developing an infection at the surgical site.

The percent of eligible ASC patients that are normothermic within 15 minutes of arrival into the Post Anesthesia Care Unit (PACU) is displayed below. Higher percentages are better.

2023Q3 Percent of Eligible ASC Patients with Normothermia

99.4%

Represents 258,522 patient admissions seen at 1,130 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: Percent of Eligible ASC Patients with Normothermia


generated graph for metric by quarter

Unplanned Anterior Vitrectomy

An unplanned anterior vitrectomy is a potential complication of cataract surgery.

The percent of ASC cataract surgery patients that experienced an unplanned anterior vitrectomy in ASC cataract surgery patients is shown below. Lower rates are better.

2023Q3 Percent of ASC Cataract Surgery Patients with Unplanned Anterior Vitrectomy

0.156%

Represents 461,657 patient admissions seen at 735 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: Unplanned Anterior Vitrectomy


generated graph for metric by quarter

Toxic Anterior Segment Syndrome (TASS)

Toxic anterior segment syndrome (TASS) is a potential complication of anterior segment eye surgery.

The frequency of TASS is shown below as a rate per 1000 anterior segment surgery patients. Lower rates are better.

2023Q3 Rate of Toxic Anterior Segment Syndrome (TASS)

0.034 per 1000 Anterior Segment Surgery Patients

Represents 295,414 patient admissions seen at 656 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: Toxic Anterior Segment Syndrome (TASS)


generated graph for metric by quarter

All Cause Emergency Department Visit Within One Day of Discharge

Patients undergoing ambulatory surgery are expected to recover at home following discharge. An emergency department visit within one day of discharge is an unexpected event.

The frequency of ASC admissions experiencing an emergency department visit within one day of discharge is shown below as a rate per 1000 admissions. Not all conditions requiring an emergency department visit result from the care the patient received in the ASC, nor can all medical conditions requiring an emergency department visit following discharge be anticipated in advance. Therefore, some level of emergency department visits following discharge is to be expected.

2023Q3 Rate of All Cause Emergency Department Visits Within One Day of Discharge

0.643 per 1000 admissions

Represents 2,077,326 patient admissions seen at 1,705 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: All Cause Emergency Department Visit Within One Day of Discharge


generated graph for metric by quarter

All Cause Unplanned Hospital Admission Within One Day of Discharge

Patients undergoing ambulatory surgery are expected to recover at home following discharge. An unplanned hospital admission within one day of discharge is an unexpected event.

The frequency of ASC admissions experiencing an unplanned hospital admission within one day of discharge is shown below as a rate per 1000 admissions. Not all conditions requiring a hospital admission result from the care the patient received in the ASC, nor can all medical conditions requiring an unplanned hospital admission be anticipated in advance. Therefore, some level of unplanned hospital admissions is to be expected.

2023Q3 All Cause Unplanned Hospital Admissions Within One Day of Discharge

0.270 per 1000 admissions

Represents 2,084,377 patient admissions seen at 1,719 ASCs between 2023-07-01 and 2023-09-30

The data trends for this measure over the last four quarters as well as an annual rate for 2022 are presented below in both tabular and graphic formats.

Data Summary: All Cause Unplanned Hospital Admission Within One Day of Discharge


generated graph for metric by quarter

For more detailed information on these measures, please review the Implementation Guide found on the home page of the ASC Quality Collaboration website at www.ascquality.org.

*For purposes of this quality report, ''admission'' is defined as completion of registration upon entry into the ASC. This term is used in order to be consistent with the measure specifications.