Quality Initiatives
We continually strive to provide excellent, quality care in a safe environment. Our organization is involved in the following state and national healthcare quality initiatives and groups:
- Accreditation Association for Ambulatory Health Care (AAAHC)
- Centers for Medicare and Medicaid Services (CMS) Healthcare Quality Alliance
- Association of periOperative Registered Nursing (AORN)
- Ambulatory Surgery Center (ASC) Quality Collaboration
- The Leapfrog Group
- National Healthcare Safety Network System (NHSN)
- Tennessee Ambulatory Surgery Center Association (TASCA)
- Ambulatory Surgery Center Association (ASCA)
Within the facility, we utilize a healthcare team to make improvements in the following areas:
- National Patient Safety Goals
- Pain Management
- Patient Flow Efficiency Throughout the Center
- Medication Safety
- Infection Control
- Patient Satisfaction
- Physician Satisfaction
Multiple areas are monitored to evaluate processes and outcomes. Some examples include:
- Surgical Appropriateness
- Sterilization of Instruments
- Pre-Procedure Time-outs
- Medication Administration Safety
- Prevention of Healthcare Acquired Infections
- Sleep Apnea Assessment
We have established an internal survey process committed to providing an ongoing consultative review of our center’s performance within quality standards. These are just a few examples of our commitment to providing a broad range of high-quality services that meet the growing and changing healthcare needs of our community.
- Click here for our current Patient Satisfaction statistics
- Click here for our current Physician Satisfaction statistics
- Click here for our current Annual National Patient Safety Goals
Patient Satisfaction
Patient surveys are a useful tool for evaluating the Methodist Surgery Center Germantown patient experience, measuring loyalty, identifying areas for improvement and assessing the effectiveness of improvement efforts. Our surgery center utilizes the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) administered through Press Ganey. Prior to OAS CAHPS, there was no standardized survey instrument to assess patient experience across outpatient surgical care facilities. By utilizing this survey, it allows our patients an objective and meaningful comparison of our measures against those of other surgical centers.
Our results are based solely on the percentage of patients giving Methodist Surgery Center Germantown an “Excellent” or a 9-10 rating score.
Measure | Our Goal | Press Ganey (National) | Our Score 2021 | Our Score 2022 | Our Score 2023 |
|---|---|---|---|---|---|
Overall "Best Facility Possible" | 92% | 88% | 93% | 94% | 96% |
Would you recommend this facility to your friends and family? | 92% | 85% | 95% | 93% | 94% |
Overall Communication | 92% | 92% | 95% | 96% | 96% |
Overall Treatment | 92% | 97% | 99% | 99% | 99% |
Overall Discharge Process | 92% | 97% | 98% | 98% | 98% |
Physician Satisfaction
Our surgery center strives to work in collaboration with our physicians, their patients and families, in providing the highest quality surgical services. We are known for our high physician satisfaction scores and working closely with our physicians to find new innovations in patient care.
These physician satisfaction surveys are distributed twice a year to help us understand what our physicians feel is important to them and their patients. Our goal is 4.5 out of a possible 5.0.
Area | 2021 | 2022 | 2023 |
|---|---|---|---|
Scheduling | * | * | 4.3 |
Admissions | * | * | 4.8 |
OR | * | * | 4.8 |
Post-op | * | * | 4.9 |
Facilities | * | * | 4.6 |
Overall | * | * | 4.9 |
*Temporarily suspended due to COVID-19
Annual National Patient Safety Goals
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.
Patient Falls | 2021 | 2022 | 2023 |
|---|---|---|---|
National Patient Fall Rate per 1000 ASC Admissions | 0.171 | 0.165 | 0.153 |
Our Patient Fall Rate per 1000 ASC Admissions | 0.21 | 0 | 0 |
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.
Patient Burns | 2021 | 2022 | 2023 |
|---|---|---|---|
National Patient Burn Rate per 1000 ASC Admissions | 0.015 | 0.015 | 0.017 |
Our Patient Burn Rate per 1000 ASC Admissions | 0 | 0 | 0 |
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.
Patient Transfers | 2021 | 2022 | 2023 |
|---|---|---|---|
National Hospital Transfer/Admission Rate per 1000 ASC Admissions | 0.94 | 0.81 | 0.80 |
Our Hospital Transfer/Admission Rate per 1000 ASC Admissions | 0.21 | 1.50 | 0.61 |
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.
Wrong SSPPI | 2021 | 2022 | 2023 |
|---|---|---|---|
National Rate of Wrong Site, Side, Patient, Procedure, Implant per 1000 ASC Admissions | 0.025 | 0.023 | 0.026 |
Our Rate of Wrong Site, Side, Patient, Procedure, Implant per 1000 ASC Admissions | 0 | 0 | 0 |
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 at the time of surgery. Normothermia helps reduce the risk of surgical complications, including the risk of developing an infection at the surgical site.
The percentage 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.
Normothermia | 2021 | 2022 | 2023 |
|---|---|---|---|
National Normothermia per 1000 ASC Admissions | 98.9% | 99.2% | 99.1% |
Our Normothermia Rate per 1000 ASC Admissions | 100% | 100% | 100% |
Anterior Vitrectomy
An unplanned anterior vitrectomy is a potential complication of cataract surgery. The percentage of ASC cataract surgery patients that experienced an unplanned anterior vitrectomy in ASC cataract surgery patients is shown below as a rate per 1000. Lower rates are better.
Anterior Vitrectomy | 2021 | 2022 | 2023 |
|---|---|---|---|
National UPV per 1000 ASC Admissions | 3.7 | 3.1 | 3.0 |
Our UPV Rate per 1000 ASC Admissions | 0 | 1.11 | 0 |
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.
TASS | 2021 | 2022 | 2023 |
|---|---|---|---|
National TASS per 1000 ASC Admissions | 0.08 | 0.08 | 0.042 |
Our TASS Rate per 1000 ASC Admissions | 0 | 0 | 0 |
Emergency Department Visit Within 24 Hours 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. Not all conditions requiring an emergency 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. The frequency of ASC admissions experiencing an emergency department visit within one day of discharge is shown below as a rate per 1000 admissions. Lower rates are better.
| ED Visit within 24H | 2021 | 2022 | 2023 |
|---|---|---|---|
National ED Visit Rate per 1000 ASC Admissions | 0.77 | 0.66 | 0.65 |
Our ED Visit Rate per 1000 ASC Admissions | 0 | 0.43 | 0.41 |
Unplanned Hospital Admission Within 24 Hours 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. Not all conditions requiring a hospital admission result from 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. The frequency of ASC admissions experiencing an unplanned hospital admission within one day of discharge is shown below as a rate per 1000 admissions. Lower rates are better.
Unplanned Admit within 24H | 2021 | 2022 | 2023 |
|---|---|---|---|
National Hosp. Visit Rate per 1000 ASC Admissions | 0.34 | 0.27 | 0.27 |
Our Hosp. Visit Rate per 1000 ASC Admissions | 0 | 1.50 | 1.02 |