Office-based surgery has become a vital component of the practice of oral and maxillofacial surgeons and periodontists. It has enabled these specialties to provide needed service to patients in an outpatient setting, including the option of intravenous sedation. It is the stance of this article to promote professional oversight and quality assurance through accreditation by the Joint Commission to maintain a standard in the delivery of office-based surgical services, thus upholding the integrity of the profession in the clinical setting.
Although general dentists do not get Joint Commission of Accreditation of Healthcare Organization (JCAHO) accreditation for their private offices, the authors believe that this article is relevant to the dental profession for many reasons. An increasing percentage of general dentists and dental specialists now practice in hospitals and other facilities that are accredited by the JCAHO and need an understanding of the accreditation process as they become leaders within these health care delivery systems. There is a national debate ongoing in the United States regarding the need for universal health care, which, if implemented, would bring along standards and regulations (understood by our medical colleagues) that the dental community also needs to understand. It is also a goal of the American Association of Oral and Maxillofacial Surgeons (AAOMS) to encourage members of their organization to seek JCAHO accreditation for their practices (some have done so), and the authors believe that periodontal practices could benefit from the information presented. Most of this article is geared to oral and maxillofacial surgeons (they have already started accrediting their offices) and, to some extent, periodontists because they are the surgical specialties of dentistry. It is also intended for the general dental community, however. Even if one does not seek accreditation for his or her office, many of the goals and standards of the JCAHO are good for safe and effective health care delivery.
The delivery of safe high-quality care and services should be the goal of all patient care facilities. As oral and maxillofacial surgeons and periodontists increase, and continue to increase, the volume and complexity of surgical procedures performed in the office, it is imperative that we maintain the quality of care that the profession has upheld in the public eye for so many years . Accreditation by a managed care agency is one definitive method through which an office-based surgery facility can attain the recognition of achieving an established standard and provide an internal “check and balance” system ensuring that a superior standard of care is being maintained. During 2000 in Florida, there were several unfavorable outcomes in the surgical office setting that sparked media attention to health and safety issues provided by office-based surgeons . Although regulations were already in place in the hospital setting, the state legislation felt the demand to become involved in regulating office-based surgical care. Surgical specialties are at risk for receiving negative attention if the complexity and volume of office-based procedures outstrip the capacity of the office to provide appropriate resources and “back-up”—particularly during emergency situations. The possibility of less than desirable surgical outcomes can easily increase in this environment. It is therefore prudent to take active and reasonable measures to implement standards ensuring that quality care is being provided. Many of these standards have been established by various regulatory agencies and organizations, with the JCAHO being one of them.
A steady increase in the cost of in-hospital health care has resulted in an increased demand for often more affordable office-based surgery. It is estimated that 15% to 20% of all outpatient operations in the medical community are now being performed as office-based surgical procedures, and in oral and maxillofacial surgery, more than 90% of the procedures are performed in the office. As many surgical procedures steadily moved from hospitals to outpatient-based settings in the early 1980s, the transfer of the oversight functions, unfortunately, did not follow . Many surgeons who could not get privileges in hospitals were able to practice in their offices. This was fairly common for cosmetic surgical procedures. State governments began to consider the need for standards to protect health consumers from inadequately trained practitioners, ill-equipped facilities, and preventable anesthesia-oriented incidents .
Oral surgeons have been among the leaders in the field of office-based surgery under general anesthesia. Third molar surgery has given the specialty its current stronghold on office-based surgery. The validity for the procedure has been well established, and this has allowed oral surgeons to become the model for other providers of office-based surgery. The removal of third molars in young adults has been a widely accepted preventive procedure proved to promote periodontal health in the second molar . In addition, the supported indications for early third molar removal include systemic health considerations, prevention of odontogenic cysts, crowding of mandibular incisors, orthodontic considerations, and pericoronitis, to name a few . A widely accepted trend has been to perform third molar surgery under office-based ambulatory anesthesia, allowing for patient comfort from anxiety through an often difficult surgical procedure. The worldwide acceptance of this practice has maintained a consistent high volume of office-based ambulatory surgery in the oral and maxillofacial surgery office setting. It is also important to consider patient satisfaction as an indication for quality care. Clinical trials in outcome assessment reveal that more than 90% of patients who have undergone oral surgery under local anesthesia, conscious sedation, or general anesthesia felt safe and reported a high level of satisfaction after surgery . This has also established oral surgery practice as a model for conscious sedation in other medical specialties, such as colonoscopy and plastic surgery.
National patient safety goals
The national patient safety goals were initially created by the Joint Commission to improve patient safety in the hospital setting. These goals have been further developed into a useful tool for providing a safe environment for patients in the ambulatory care and office-based surgical setting. These goals can be applied specifically to the oral and maxillofacial surgery practice and can also be modified for the larger general practice or multispecialty office.
The Joint Commission has implemented these goals, focusing on problematic areas in health care delivery, in the accreditation process and requirements. When an organization does not demonstrate implementation of a safety goal requirement, it is assigned a requirement for improvement similar to the requirement for improvement assigned to compliance with a standard. In the accreditation process, all requirements for improvement with regard to national patient safety goals must be addressed .
The national patient safety goals applicable to the oral and maxillofacial surgery office address problematic areas, such as the following:
- 1.
Improving the accuracy of patient identification
- 2.
Improving the effectiveness of communication among caregivers (accuracy of referral requests)
- 3.
Improving the safety of using medications
- 4.
Reducing the risk for health care–associated infections
- 5.
Accurate and complete reconciliation of medications across the continuum of care
- 6.
Reducing the risk for surgical fires
- 7.
Encouraging patients’ active involvement in their own care as a patient safety strategy
- 8.
Universal protocol with regard to correct patient and surgery site identification at the time of surgery
A brief summary of each goal requirement is given here; the detailed goal description, rationale, implementation, and expectation of requirement can be found on the Joint Commission Web site .
Improving the accuracy of patient identification
Use at least two patient identifiers when providing care, treatment, or services to prevent patient errors in diagnosis and treatment. This is important in the practice with multiple doctors or in hospital practices in which charts may be switched.
Improving the effectiveness of communication among caregivers
It is important for general practitioners who refer patients to dental specialists that the request for service requested is clear. Wrong tooth extractions and other such errors can lead to embarrassment, malpractice suits, and irreversible harm to the patient. Likewise, surgeons and endodontists, for example, should be careful with referrals and communicate with the referrer if there is ever the slightest doubt.
Within the hospital setting or when communicating with nurses, clerks, or laboratory personnel, verify verbal or telephone orders by having the complete order or test result “read-back” by the receiving personnel. This promotes effective communication, and thus reduces critical errors in patient care. In addition, the standardization of abbreviations and assessment of timely reporting of critical test results are important. The Joint Commission recommends a “hand-off” approach to communication in which caregivers take time and opportunity to ask and respond to questions when changing shifts or transferring a patient to postanesthesia recovery areas.
Improving the safety of using medications
Review and identify sound-alike drugs, and provide an effective method of labeling all medications. Syringes used during intravenous sedation should be labeled.
Reducing the risk for health care–associated infections
An organization should be in absolute compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, thus decreasing the transmission of infectious agents from staff to patients. Nearly all states and jurisdictions in the United States require dentists to have proof of having completed a course in infection control as a part of being credentialed for licensure or renewal. Occupational Safety and Health Administration (OHSA) requirements for dental practice must also be in place, and supporting documents must be kept in the office.
Accurate and complete reconciliation of medications across the continuum of care
Communication of a complete list of current patient medications to compare with those ordered should be ensured in providing a continuum of patient care. An accurate and updated medication list should be maintained as a part of the medical history. Practitioners should be aware of drug interactions, and there are several handheld electronic devices that should be used to check for possible drug interactions when a new drug is being added.
Reducing the risk for surgical fires
Educate staff in maintaining and monitoring heat and fuel sources in consideration of timely patient intervention in the event of a surgical fire.
Encouraging patients’ active involvement in their own treatment
Provide a method and means of communicating with the patient and patient’s family regarding all aspects of treatment and services to be rendered. Involving patients in their own health care decisions improves acceptance of the proposed surgical procedure, alleviates misunderstandings, and prevents malpractice claims.
Universal protocol
Implement a preoperative verification process to prevent wrong site, wrong patient, and wrong procedure surgery. Review relevant documents, such as the patient consent, history and physical examination findings, relevant images before the start of the procedure, and implementation of a “time-out” protocol in which the procedure team provides final verification of patient and procedure. It is not required by the JCAHO that teeth be marked on the patient or on radiographs as part of the site verification process. Nevertheless, it is required that teeth to be extracted or treated be listed by numbers (1–32) in the patient’s medical records. Implant sites can be marked on the radiographs.
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