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  • Measure Summary
  • NQMC:010053
  • Oct 2015

Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant.

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: ASC Quality Collaboration. ASC quality measures: implementation guide. Version 2.0. Ambulatory Surgery Center; 2014 Jan. 32 p.

Primary Measure Domain

Clinical Quality Measures: Outcome

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of Ambulatory Surgery Center (ASC) admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant.

Rationale

"Surgery performed on the wrong body part," "surgery performed on the wrong patient," and "wrong surgical procedure performed on a patient" have all been endorsed as serious reportable surgical events by the National Quality Forum (NQF, 2007). This outcome measure serves as an indirect measure of providers' adherence to the Joint Commission's "Universal Protocol" guideline (2012) for eliminating wrong site, wrong procedure, wrong person surgery. The Universal Protocol is based on the consensus of experts and is endorsed by more than forty professional medical associations and organizations. In order to encompass the outcomes of all key identification verifications, the Ambulatory Surgery Center (ASC) Quality Collaboration's measure incorporates not only wrong site, wrong side, wrong patient and wrong procedure, but also wrong implant in its specifications.

Clinical Practice Guidelines
The Joint Commission's "Universal Protocol" is based on the consensus of experts from the relevant clinical specialties and professional disciplines and is endorsed by more than 40 professional medical associations and organizations.

Evidence for Rationale

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

National Quality Forum (NQF). Serious reportable events in healthcare - 2006 update: a consensus report. Washington (DC): National Quality Forum (NQF); 2007 Mar. 60 p.

The Joint Commission (TJC). The universal protocol for preventing wrong site, wrong procedure, and wrong person surgery[TM]. Oakbrook Terrace (IL): The Joint Commission (TJC); 2012 Nov 26. 1 p.

Primary Health Components

Ambulatory Surgery Center (ACS); wrong site; wrong side; wrong patient; wrong procedure; wrong implant

Denominator Description

All Ambulatory Surgery Center (ASC) admissions (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

All Ambulatory Surgery Center (ASC) admissions experiencing a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

The measures included in this implementation guide have been developed using a multi-step process. Each has been vetted with both an internal panel of technical experts and an external panel of individuals and/or organizations with relevant expertise. All of the measures have been pilot tested in Ambulatory Surgery Centers (ASCs) and assessed for validity, feasibility and reliability.

Evidence for Extent of Measure Testing

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Pay-for-reporting

Public reporting

Measurement Setting

Ambulatory Procedure/Imaging Center

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

All ages

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Safety

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Encounter

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All Ambulatory Surgery Center (ASC) admissions*

*Admission: Completion of registration upon entry into the facility.

Exclusions
None

Exclusions/Exceptions

None

Numerator Inclusions/Exclusions

Inclusions
All Ambulatory Surgery Center (ASC) admissions experiencing a wrong* site, wrong side, wrong patient, wrong procedure, or wrong implant

*Wrong: Not in accordance with intended site, side, patient, procedure or implant.

Exclusions
None

Numerator Search Strategy

Encounter

Data Source

Paper medical record

Other

Type of Health State

Adverse Health State

Instruments Used and/or Associated with the Measure

Sample Data Collection Sheet: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Wrong site, wrong side, wrong patient, wrong procedure, wrong implant.

Measure Collection Name

Ambulatory Surgery Center (ASC) Quality Measures

Submitter

Ambulatory Surgery Center (ASC) Quality Collaboration - Health Care Quality Collaboration

Developer

Ambulatory Surgery Center (ASC) Quality Collaboration - Health Care Quality Collaboration

Funding Source(s)

Ambulatory Surgery Center (ASC) providers; nursing, physician, and provider associations

Composition of the Group that Developed the Measure

Ambulatory Surgery Center (ASC) providers; nursing, physician, and provider associations; provider accrediting organizations

Financial Disclosures/Other Potential Conflicts of Interest

None

Measure Initiative(s)

Ambulatory Surgery Center Quality Reporting Program

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: ASC Quality Collaboration. ASC quality measures: implementation guide. Version 2.0. Ambulatory Surgery Center; 2014 Jan. 32 p.

Source(s)

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

Measure Availability

Source available from the Ambulatory Surgery Center (ASC) Quality Collaboration Web site External Web Site Policy.

For more information, contact the ASC Quality Collaboration's Executive Director, Donna Slosburg, at E-mail: donnaslosburg@ascquality.org; Web site: ascquality.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on September 10, 2008. The information was verified by the measure developer on December 3, 2008.

This NQMC summary was retrofitted into the new template on May 31, 2011.

This NQMC summary was updated by ECRI Institute on July 10, 2012. The information was verified by the measure developer on August 1, 2012.

This NQMC summary was updated again by ECRI Institute on August 3, 2015. The information was verified by the measure developer on September 11, 2015.

Copyright Statement

No copyright restrictions apply.

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