The American Society of Plastic Surgeons last month finalized a bylaw that essentially requires members to seek accreditation for office surgery suites, or risk losing ASPS membership. The new rule is a response to public concerns about safety, and attempts to raise the standards followed by plastic surgeons, ASPS says.

"Accreditation of surgical facilities is really the gold standard for safety. Several states have been moving in this direction, and ASPS has been discussing it since 1995. We wanted to be in the forefront of the trend," says Ronald Iverson, MD, past president of ASPS and chairman of an ASPS task force on public safety.

In 1998, ASPS surveyed its members, and found that only about half were operating in accredited facilities. Many of those using unaccredited facilities said they did not intend to seek accreditation.

"There seemed to be a fairly strong notion that, since these surgeons had been safely using non-accredited facilities, there was no significant reason to seek accreditation," Dr. Iverson says.

The new rule stipulates that plastic surgery performed under anesthesia "other than minor local anesthesia and/or minimal oral tranqulization" must be done in a facility that meets one of these criteria:

• Accreditation by a state- or nationally recognized accrediting agency such as the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC), or the Joint Commission on the Accreditation of Health Care Organizations(JCAHO)

• Certification to participate in the Medicare program under Title XVIII.

• Licensing by the state in which the facility is located

Passed by a large majority, the new rule still aroused criticism from members who objected to the cost of meeting accreditation standards, Dr. Iverson says. Though accreditation fees may cost only $1,000 to $3,000 a year, bringing a facility up to standard can cost as much as $100,000 in equipment, facility renovations or supplies. Then the surgical suite operator may incur ongoing increased costs due to staffing requirements.

"It is a complex process to bring an outdated facility up to speed. But there is also value; this is how we can assure the public that surgical facilities are safe," says Dr. Iverson, who also happens to be president of AAAASF.

ASPS has mandated a gradual phase-in, with all members expected to meet the new rule by July 1, 2002. From that time on, when renewing membership, each surgeon will be required to sign a statement that he or she is practicing in an accredited facility. A surgeon who refuses to sign the statement will be placed on probation, and ultimately denied membership. In addition, ASPS has reporting procedures for surgeons who believe colleagues are violating the rule.

"We aren't going to send out site inspection teams or anything," says Dr. Iverson. "This is an honor system. But this is the standard that plastic surgeons, and all surgical specialties, need to follow."

Florida Panel Recommends Study, Tighter Controls
An ad-hoc panel studying office surgery in Florida concluded that it "could not make a sound judgement" about whether adverse events were any more common in office-based surgery suites than in ambulatory surgery centers and hospitals. But it did recommend more fact gathering and somewhat tighter regulation of office-based surgery facilities there.

In August, following the deaths of five patients in office surgery facilities, the Florida Board of Medicine declared a three-month moratorium on office surgery requiring general anesthesia. It then appointed the Commission on Outpatient Surgical Safety to learn why the adverse events were occurring and make recommendations about what to do. The group included 12 physicians, three consumers and one hospital risk manager.

After examining the recently reported adverse events, the group reported that the data on office surgery were "insufficient" to assess the risk of death and morbidity resulting from surgery in offices. The group wrote that it could not conclude "that there is an industry-wide safety problem."

But it recommended several changes in Florida's current office surgery regulations. Among other items, the commission advises that office surgery suites:

• maintain surgical logs for nearly all cases done in offices once a month for one year, for data collection purposes;

• maintain written transfer agreements with hospitals, as ASCs in the state must do;

• abstain from level III surgery (general anesthesia) on ASA III and higher patients (those with severe systemic disease);

• do EKGs and workups on all ASA II patients over 40 who are undergoing level III surgery;

• Have all anesthesia equipment inspected and calibrated by a licensed technician every six months.

The Medical Board was scheduled to review the recommendations on Nov. 5. The moratorium was scheduled to end on Nov. 8.

In Michigan, ASCs and Blue Cross Continue to Tangle
In Michigan, ASCs and Blue Cross Continue to Tangle

For years, BCBSM has resisted paying for procedures in independent physician-owned ASCs, arguing that an increase in these facilities would increase surgical procedures overall.

The insurer's policies may have hampered surgery-center growth in Michigan: The state ranks 43rd in the US in the number of outpatient surgery centers; there are only 22 independent centers in the state.

Last March, Michigan Insurance Commissioner Frank Fitzgerald ordered the company to change that with a new policy due the end of December. He ruled that the BCBSM "provided no data to support" its conclusions that ASCs increase the volume of surgery. He further observed that "????- ?it seems that failure to participate with physician-owned ambulatory surgery facilities in many cases denies members the highest quality of care." The ruling came after more than 600 patients of independent surgical facilities, as well as healthcare professionals and representatives of the Michigan Ambulatory Surgery Association (MASA) sent letters to the state's Insurance Bureau. The letters testified that although ASCs provide high-quality, low-cost care, Blue Cross's reimbursement policies oblige patients to have most outpatient procedures done in hospitals.

MASA representatives are concerned that the new plan may not address some items that ASCs currently find problematic. A preliminary draft in September, for example, required single-specialty centers to have two ORs and multispecialty centers to have three, a requirement Linda Kirk, RN, an officer of MASA and one of its founders, says many find unfair.

Ms. Kirk says BCBSM has been open to input, listening to concerns and expressing interest in a liaison committee involving MASA, but has yet to set up any meetings. "We'd like to have a voice in the plan," she says. "We've given feedback, and now we'd like to know how areas of concern are being addressed, like 'evidence of need' issues, and the minimum requirement for ORs." As the deadline for the plan is December, there isn't much time.

If Mr. Fitzgerald finds the proposal unsatisfactory, he has the authority to rewrite the plan himself. An acceptable plan, according to the Insurance Bureau, will "assure that in any given area of the state, a BCBSM member has reasonable access to certificate-covered ambulatory surgical care, whenever such services are required."

A BCBSM spokesperson failed to return repeated phone calls.

Road to Less Pain
New standards for both acute and chronic pain management will take effect on January 1, 2001, an event some physicians are hoping will not only raise expectations of assessment and management of pain in health care organizations, but raise patients' expectations of treatment as well. The standards are expected to apply to all accredited US health care facilities, and are a collaborative effort between the Joint Commission on the Accreditation of Healthcare Organizations, the University of Wisconsin-Madison Medical School, and researchers from such places as the University of Chicago and Duke University.

The Joint Commission Standards on Pain Management provides an organizational structure for assessing, monitoring, and treating pain. The standards are designed to help make sure that patients' complaints are taken seriously, and to assist healthcare workers in evaluating pain or the likelihood of pain.

Jeffrey Apfelbaum, MD, a professor at the University of Chicago and director of outpatient surgery at the University of Chicago Hospitals, is calling for pain to be considered the "fifth vital sign." At a recent meeting of pain management experts, Dr. Apfelbaum, who studies acute-pain issues, presented the results of a survey of 250 patients who had surgery at ambulatory centers, hospitals, clinics, or doctors' offices within the past five years. Eighty-six percent of the patients said they experienced moderate to extreme post-operative pain (18 percent said they experienced extreme pain). Yet half of the patients said they were "satisfied" with the pain medicine they received before leaving a facility, and 40 percent were "very satisfied" with their pain management after going home. "Patients have come to expect pain, and consequently, they accept it," explains Dr. Apfelbaum. But, he says, they don't have to suffer this way. "We hope that patients begin to understand the issues involved????-???????-???that they have treatment options for pain."

He applauds the development of new drugs such as the COX- 2 pain medications, which can minimize or eliminate the use of narcotics like morphine and codeine. According to Dr. Apfelbaum, many patients refuse narcotics, choosing to deal with intense pain because they fear addiction or loss of control. Getting patients to talk about their fears can help doctors both devise practical treatment plans for those patients and educate them.

He sees the standards as "a very detailed way to educate physician practitioners," and says, "We need to find ways to assess pain other than patient satisfaction, and we need to encourage open dialogue between physicians and patients. Although we have been diligent, we need to do a better job for our patients." Visit www.jcaho.org for the Joint Commission Standards.