Safe Surgery Checklist | Joint Commission
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Safe Surgery Checklist

July 24, 2012

The Centers for Medicare and Medicaid Services (CMS) is implementing a new quality reporting program for ambulatory surgery centers that introduces a structural measure on the use of a safe surgery checklist (ASC-6).  This measure is part of payment determination for the calendar year 2015.  This measure is also being adopted for the Hospital Outpatient Quality Reporting Program asOP-25 for the calendar year 2014.  Beginning in 2013, ambulatory surgery centers and hospitals would report their yes/no response regarding the use of a safe surgery checklist in 2012.

The use of a checklist creates an expectation that organizations assess effective communication and safe practices during three perioperative periods: prior to administration of anesthesia; prior to skin incision; and prior to the patient leaving the operating room or procedural area.  Through a CMS-designated website, organizations are expected to annually report whether or not a checklist was used for surgery.  There is no penalty for not using a checklist.

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 different checklists that can be used.  The World Health Organization (WHO) and The Joint Commission are specifically cited as resources in the rules.  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 the retention of foreign bodies or assessment of the patient’s risk of blood loss in terms of the units of blood available.   It is expected that the ongoing refinement of checklists will continue.  The Joint Commission encourages organizations to supplement the UP with additional good practices that will increase patient safety. 

The same structural measure was proposed for the Hospital Inpatient Quality Reporting Program for payment determination in fiscal year 2016 and beyond.  The final rule is anticipated to be issued in early August.

Additional information on these programs and measures can be found at the CMS QualityNet website