Quality Management in Outpatient Surgical Care

Fred E. Shapiro, DO Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Lucinda L. Everett, MD, MHCM Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts

Richard D. Urman, MD, MBA Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts


As the practice of medicine continues to evolve, we stand to benefit from taking initiative to improve quality and safety in ambulatory surgery. Medicine’s focus on quality and safety has been gaining momentum for many years. In 1999, in their first report, To Err is Human, the Institute of Medicine’s Committee on Quality of Health Care in America assessed and identified the problem.1 Their second report, published in 2001, Crossing the Quality Chasm, drew national attention by highlighting 6 characteristics of desired state care: safe, effective, patient centered, timely, efficient, and equitable. It also recognized that financial incentives would provide motivation and reward for the implementation of care based on applying best practices and achieving better outcomes. There are several models that have been proposed regarding how to facilitate high-quality health care, and much of the infrastructure can be applied to the ambulatory setting. Dougherty and Conway2 proposed a “3T model” outlined in Figure 1. This model describes 3 translational steps, beginning with basic science (T1), advancing to clinical research (T2), and testing activities (T3) leading to evidenced-based interventions that can be reliably used in all patients in all settings. Examples of these testing activities (T3) include measurement and accountability of health-care cost, implementation of interventions and system redesign, scaling and spreading of effective interventions, and research. REPRINTS: LUCINDA L. EVERETT, MD, MHCM, HARVARD MEDICAL SCHOOL, MASSACHUSETTS GENERAL HOSPITAL, BOSTON, 02114 MA. E-MAIL: [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 1, 97–108 r 2014, Lippincott Williams & Wilkins

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Figure 1. T1, T2, and T3 represent the 3 major translational steps in the proposed framework to transform the health care system. The activities in each translational step test the discoveries of prior research activities in progressively broader settings to advance discoveries originating in basic science research through clinical research and eventually to widespread implementation through transformation of health care delivery. Double-headed arrows represent the essential need for feedback loops between and across the parts of the transformation framework. T indicates translation. Reproduced with permission from Dougherty and Conway.2 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

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Quality Management in Outpatient Surgical Care


Conway and Clancy,3 in support of the 3T model, suggested that investments should be made in key drivers of change in health care. Examples described include health information technology; comparative effectiveness, especially in the treatment of chronic conditions; quality improvement collaboration; and clinical training that includes learning how to measure results and incorporate evidence into practice. Hoffman and Emanuel4 emphasize that there is not a single solution to reconstruct health-care delivery. They assert that the entire process will require an organized systematic approach through “rethinking, redesigning, and then applying necessary tools,” focusing on health outcomes, the value of health interventions, and patients. This is consistent with the Institute for Healthcare Improvement Plan, Do, Study, Act5 cycle model for improvement. The Department of Health and Human Services developed the National Quality Strategy to create aims and priorities to guide national efforts to improve the quality of health care.6 These 3 aims include: (1) better care that is patient centered, reliable, accessible, and safe; (2) healthy people in healthy communities; and (3) reduced costs. These aims align with the implementation of checklists in ambulatory surgery discussed below. Value-based purchasing is a construct for health care that incorporates The National Quality Strategy’s aims for the provision of care that is both high quality and cost-effective. The domains of quality measurements reflect the principles of patient safety, patient-centered experience and outcomes, improved care coordination, efficiency and cost reduction, and population health, among others (Table 1). Table 1.

Six Domains of Quality Measurement


Sample Types of Measures

1. Safety

Patient safety, health care–acquired conditions Patient experience, caregiver experience, patient-reported outcomes Admission and readmission measures, care coordination measures, provider communication Acute care, chronic care, prevention, clinical process measures, and outcomes Health-related behaviors, access to care, determinants of health, disparities Annual spending measures (eg, per capita spending), episode cost measures, quality-to-cost ratios

2. Patient-centered and caregivercentered experience and outcomes 3. Care coordination 4. Clinical care 5. Population or community health efficiency and cost reduction 6. Efficiency and cost reduction

Reproduced with permission from Dougherty and Conway.2 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. www.anesthesiaclinics.com


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The Center for Medicare and Medicaid Services (CMS) value-based purchasing strategy explicitly links facility and physician compensation to the quality of health-care outcomes, and includes a call for valuebased purchasing in ambulatory surgery centers. This strategy aims to simultaneously address the 2 most pressing problems in health care— quality and cost. Initially, quality was assessed using process measures, as opposed to outcome measures, because of concerns over the adequacy of risk adjustment. Payment was linked solely to participation in the submission program with the annual hospital Medicare update being at risk. All hospitals had a withhold of payment beginning at 1% in FY 2013 and rising to 2% by FY 2017. The money that is withheld will be redistributed to hospitals based on their Total Performance Scores.

Outcomes and Quality in Ambulatory Anesthesia and Surgery

Because ambulatory anesthesia is generally low risk compared with inpatient surgery, the outcomes of interest are (1) appropriate patient selection to avoid excessive rates of unanticipated admission or readmission; (2) identification and avoidance of rare but serious adverse events; and (3) minimizing side effects such as postoperative nausea and vomiting and pain, to support an early return to functional status. In addition, ambulatory settings are generally associated with higher efficiency and lower cost. Rates of unanticipated admission in ambulatory surgery are generally considered acceptable in the range of 0.5% to 1.5%.7,8 Unanticipated admissions often result from poor pain control, intractable vomiting, or surgical complications. Data from the National Surgical Quality Improvement Project (NSQIP) from 2011 showed that readmissions in plastic surgery were associated with patient factors (procedure type, obesity, and anemia) or the development of postoperative complications, either surgical or medical.9 Fleisher et al10 proposed a risk index for prediction of admission. Return to hospital after ambulatory surgery is difficult to assess because of data limitations, but Twersky et al11 found a rate of 1.3% return related to ambulatory surgery, and a Canadian study from a health system with unified records found a very low rate of 0.15% return to hospital related to the original surgery.12 Morbidity after ambulatory surgery is largely attributed to unrecognized patient co-morbidity or to unrelated causes.13 However, venous thromboembolic events (VTE), particularly after abdominoplasty, were identified as a significant cause of mortality in a database analysis by the American Association for the Accreditation of Ambulatory Surgery www.anesthesiaclinics.com

Quality Management in Outpatient Surgical Care


Facilities.14 Thirteen of the 23 deaths in 1.1 million outpatient plastic surgery procedures were attributable to pulmonary embolism. An analysis of 30-day VTE from NSQIP data identified pregnancy, age above 60 years, active cancer, obesity, operative time >120 minutes, and certain types of venous surgery as independent risk factors for VTE after outpatient surgery.15 There is a great interest in shifting as many cases as can be safely done on an outpatient basis to the ambulatory setting. Multiple series suggest that this can be done safely and possibly with superior results. Accurate risk adjustment to ensure appropriate comparison is important for this analysis and is not always easy to obtain. However, analysis of inpatient versus outpatient lumbar discectomy from the NSQIP data set showed that, after adjusting for confounders using propensity score matching and multivariate logistic regression analysis, outpatients had lower overall complication rates.16 Similarly, after adjusting for demographic and operative variables, the NSQIP data showed that patients having laparoscopic hysterectomy as outpatients were less likely to experience wound complications, medical complications, or deep vein thrombosis, and were not more likely to require reoperation.17 Stack et al18 reported on over 38,000 outpatient thyroidectomies in the University Health System Consortium database. Complications including wound infection and hematoma were significantly lower in the outpatients; however, the outpatients were younger and healthier than those who had inpatient surgery. ’

Quality Management in Ambulatory Surgery Centers: Recent Updates G-Codes

CMS demonstrated its vision of future care by requiring, as of October 1, 2012, ambulatory surgery centers (ASCs) to start reporting quality data “G-codes” on 5 measures (Table 2) or face future Medicare payment reductions. ASCs will include the G-code corresponding to the Medicare patient’s experience under the procedure code(s) in box 24 D of the CMS-1500 claim form (http://www.ascassociation.org/ASCA/ FederalRegulations/Medicare/QualityReporting). The number of G-codes reported on the claim form will range from 2 to 5:  One G-code that corresponds to the timing of prophylactic IV antibiotic administration will be reported on all claims.  An additional G-code, G-8907, will be reported if the patient does not experience any of 4 specific adverse events (patient burn, patient fall, wrong site/side/patient/procedure/implant, or hospital transfer/ admission). www.anesthesiaclinics.com


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Table 2. G Codes Corresponding Quality Measure





Patient burn


Patient burn


Patient fall in ASC facility


Patient fall in ASC facility


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


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


Hospital transfer/admission


Hospital transfer/admission


Timing of prophylactic antibiotic administration


Timing of prophylactic IV antibiotic administration


Timing of prophylactic IV antibiotic administration


Patient documented not to have experienced any of the following events: a burn before discharge; a fall within the facility; wrong site/side/patient/procedure/ implant event; or a hospital transfer or hospital admission upon discharge from the facility Patient documented to have received a burn before discharge Patient documented not to have received a burn before discharge Patient documented to have experienced a fall within the ASC Patient documented not to have experienced a fall within the ASC Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant event Patient documented to have experienced a hospital transfer or hospital admission upon discharge from ASC Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from ASC Patient with preoperative order for IV antibiotic SSI prophylaxis, antibiotic initiated on time Patient with preoperative order for IV antibiotic SSI prophylaxis, antibiotic not initiated on time Patient without preoperative order for IV antibiotic SSI prophylaxis

ASC indicates ambulatory surgery center; SSI, surgical site infection. Reproduced with permission from ASCA Association website (http://www.ascassociation.org/ ASCA/FederalRegulations/Medicare/QualityReporting). Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.


Quality Management in Outpatient Surgical Care


 An additional 4 G-codes, each corresponding to 1 of the 4 specific adverse events, will be reported if the patient does experience one or more of the adverse events. Beginning in 2012, CMS phased in a new quality reporting program for ASCs. In addition to G-codes and already existing reportable quality measures, there is a new provision for surgical volume tracking and the use of safe surgery checklists. As ASCs will be required to report on these last 2 measures beginning in 2013, they should already have data collection mechanisms in place to track their activities during 2012. If ASCs fail to report the required quality measures, they will face a 2% reduction in their Medicare payments. Additional reportable quality measures, such as influenza vaccination coverage among health-care professionals, will likely be added in the near future. Checklists

The use of checklists is among the expectations and requirements for ASCs because of their demonstrated efficacy in both quality improvement and patient safety in tertiary care centers. Because CMS is not dictating the use of a particular checklist, ASCs are free to select the checklist that meets their individual needs. It is also important to note that, although CMS uses the name “safe surgery” checklist, the measure applies to all ASC procedures, including those that are generally considered to be diagnostic and pain management procedures (eg, certain endoscopies and injections for controlling pain). Several organizations have developed template checklists that can be adjusted to suit the needs of a particular ASC or office-based facility, including the World Health Organization, Association of periOperative Registered Nurses, American Gastroenterological Association, American College of Gastroenterology, American College of Surgeons, and The Institute for Safety in Office-Based Surgery, just to name a few. The Institute for Safety in Office-Based Surgery has worked to this end of shared responsibility and data collection on outcomes measures by creating checklists for both providers and patients. As we forge ahead with consistent and widespread implementation of electronic health records, checklists such as these will only become easier to implement and track, making improvements in care more timely and effective. Patient Satisfaction Surveys

The Agency for Healthcare Research and Quality and its Consumer Assessment of Healthcare Providers and Systems (CAHPS) Consortium, in partnership with CMS, has developed standardized surveys to collect www.anesthesiaclinics.com


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data on patient’s experiences with and ratings of care. CMS has already implemented CAHPS surveys for health and drug plans, hospitals, and home health agencies. The American College of Surgeons has developed a “CAHPS Surgical Care Survey,” which includes items about communication with the anesthesiologist (http://www.facs.org/ahp/ cahps). A January 2013 CMS request for information19 discusses the development of a standardized hospital outpatient surgical department/ ASC Experience of Care Survey, which would be submitted to the Agency for Healthcare Research and Quality for recognition as a CAHPS survey. This survey would evaluate care from the perspective of adult patients (18 y old and above) who have had surgery or procedures in these facilities, and would help consumers make informed choices about providers and improving the quality of care. Accreditation Agencies Quality Initiatives

Standards All of the major national accreditation and standards agencies [The Joint Commission, the American Association for Accreditation of Ambulatory Surgery Facilities, and the Accreditation Association of Ambulatory Health Care (AAAHC)] have released requirements and guidelines to be followed in achieving a threshold of quality improvement activities leading to improved patient care and safety for ambulatory surgical centers. For example, the AAAHC defines their expectation of organizations as20:  Striving to improve the quality of care and to promote more effective and efficient utilization of facilities and services while maintaining an active, integrated, organized, ongoing, data-driven, peer-based program of quality management and improvement that links peer review, quality improvement activities, and risk management in an organized, systematic way (https://eweb.aaahc.org/docs/obs/OBSGB11.pdf).  Implementing quality monitoring by collecting data about a specific aspect of performance such as complications, infections, patient falls, adverse incidents, building safety issues, review of medical record documentation, on-time starts, no-shows, patient satisfaction, and access to care.  Benchmarking through systematic comparison of products, services, or work processes of similar organizations, departments, or practitioners to identify the best practices known to date for the purpose of continuous quality improvement. The organization’s performance can then be compared with internal and external benchmarks as well as to other sources such as patient satisfaction surveys, financial data, medical/legal issues, and outcome data. www.anesthesiaclinics.com

Quality Management in Outpatient Surgical Care


Accreditation Electronic National Evaluation and Information Data Set To further their mission to enable data collection for benchmarking, the AAAHC created the Accreditation Electronic National Evaluation and Information Data Set (AENEID). This arose from the fact that during each AAAHC survey 700 data points are generated, a large resource of information on ambulatory health-care accreditation. Currently, data are being used to determine those standards with which organizations have difficulty, to develop educational tools for both organizations seeking accreditation, and training/retraining surveyors. An additional use for AENEID is to segment information for specific groups. For example, accredited ASCs owned or managed by a single corporate entity have been provided with aggregated information to use in their own accreditation preparation, benchmarking, and quality improvement efforts. In the future, AENEID can be utilized in response to a regulatory environment requiring performance measurement data in promoting quality by detailing evidence-based practices in these organizations. Quality Institute Studies The AAAHC Quality Institute developed a mechanism by which an AAAHC-accredited organization has an opportunity to participate in a 6-month study to identify external benchmarks and best practices in surgical procedures that include cataract extraction, colonoscopy, knee arthroscopy, shoulder surgery, and low back injection for pain management. Waiting, procedure, and discharge times are measured, as these are largely controllable and subject to improvement. Aspects such as anesthesia selection, diagnostic indications, instrument processing, complications, and outcomes are also studied. New surgical procedures (cystoscopy, endoscopy, blepharoplasty, nasal turbinate surgery, skin/subcutaneous tissue excision or destruction) are to be added to this list. Outcome Reporting and Registries

The collection of prospective data in clinical outcome registries is a mechanism to allow more accurate assessment of outcomes and links to causative factors. The value of administrative data from sources such as Medicare claims data is controversial; a recent comparison of the NSQIP database (described below) with Medicare inpatient claims data showed poor agreement between clinical and claims data for identifying patientlevel complications.21 The Surgical Care Improvement Project is a collaborative effort to reduce surgical complications; participants include CMS, the Joint Commission, and professional societies (including the American College of Surgeons and American Society of Anesthesiologists). Areas of initial focus included surgical site infections, venous thromboembolism, www.anesthesiaclinics.com


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perioperative respiratory complications, and appropriate use of b blockers. Initial analysis suggested that implementing the global Surgical Care Improvement Project bundle reduced complications; however, the overall efficacy remains somewhat controversial.22 The American College of Surgeons’ NSQIP is a risk-adjusted, prospective, observational database that grew out of a similar program across the country’s VA hospitals. ASC-NSQIP collects outcomes on a sample of surgical cases and analyzes observed versus expected results. Where performance is better than expected, it is possible to learn from best practices; low performance offers an opportunity to improve at the local level. The NSQIP sample is weighted toward high acuity cases, but includes ambulatory surgery as well. A recent analysis performed to evaluate whether the inclusion of ambulatory cases added value found that, although the morbidity and mortality were much lower than inpatient cases, the burden was still significant because of the large number of ambulatory cases, and therefore it was important to continue to monitor outcomes in ambulatory surgery.23 While anesthesiology has been a leader in some aspects of safety, we have somewhat lagged behind our surgical colleagues in the development of robust prospective databases. However, great strides have been made in the last several years, as registry projects have been constructed, and thought leaders have recognized the need for common data elements and definitions, and a way to aggregate and learn from data. The Anesthesia Quality Institute, founded by the American Society of Anesthesiologists, sponsors an incident-reporting framework known as the Anesthesia Incident Reporting System and the National Anesthesia Clinical Outcomes Registry (NACOR). NACOR accepts any electronic data, with the minimum data set being that available from billing data. As of 2012, NACOR had information from 120 practices and 1000 facilities, representing 7000 providers and 3.7 million cases. Much of the initial information is descriptive, giving a profile of age, ASA status, type of anesthesia, and surgical duration. The Society for Ambulatory Anesthesia (SAMBA) has developed a per case clinical registry of patient outcomes called the SAMBA Clinical Outcomes Registry. The registry currently contains over 60,000 ambulatory anesthesia cases. Initial findings show an overall low incidence of postoperative and postdischarge nausea and vomiting, but a significant incidence in certain case types.24 Similarly, a subset of cases shows opportunity for the improvement in postoperative pain management. The incidence of serious complications is extremely low in this ambulatory data set. The registry allows participants to see their outcomes compared with aggregated data for similar case types, and can serve as a basis for local quality improvement efforts. The Society for Pediatric Anesthesia maintains an incident-reporting registry called Wake Up Safe (http://www.wakeupsafe.org/), which has www.anesthesiaclinics.com

Quality Management in Outpatient Surgical Care


reported clusters of events such as wrong-side surgery/regional anesthesia, medication errors, and hyperkalemia from transfusion. SPA also sponsors the Pediatric Regional Anesthesia Network, which recently reported on over 14,000 pediatric regional blocks.25 The Pediatric Sedation Research Consortium has published on over 131,000 pediatric sedation cases demonstrating good overall safety.26 ’


The profession of anesthesiology has a unique opportunity to deliver high-quality, cost-effective care in alignment with national efforts. While anesthesiology has taken a leadership role in safety in the past, there is room to grow in enhancing safety, providing an appropriate level of preoperative evaluation, and minimizing waste in the system. We particularly need to understand and generalize best practices to provide a reliably high-quality process. Large numbers of Medicare beneficiaries have outpatient surgery, making this an important area of focus for CMS’s emphasis on value-based purchasing. Relevant areas in quality management for outpatient surgery include reporting of G-codes for adverse events in ASCs; the use of the surgical safety checklist; CMS initiation of patient satisfaction surveys; and development of the data infrastructure that will allow us to evaluate and continuously improve our results. Registry projects in surgery have demonstrated value in understanding best practices and areas for improvement, and the recently developed projects in anesthesiology offer similar promise.

The authors have no conflicts of interest to disclose.


1. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000. 2. Dougherty D, Conway PH. The “3T’s” road map to transform US health care: the “how” of high-quality care. J Am Med Assoc. 2008;299:2319–2321. 3. Conway PH, Clancy C. Transformation of health care at the front line. J Am Med Assoc. 2009;301:763–765. 4. Hoffman A, Emanuel EJ. Reengineering US health care. J Am Med Assoc. 2013;309:661–662. 5. Langley GJ, Moen R, Nolan KM, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009. 6. US Department of Health and Human ServicesReport to Congress, National Strategy for Quality Improvement in Health Care (March 2011). Available at: http:// www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm. Accessed November 14, 2013. www.anesthesiaclinics.com


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7. Gold BS, Kitz DS, Lecky JH. Unanticipated admission to the hospital following ambulatory surgery. JAMA. 1989;262:3008–3010. 8. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery–a prospective study. Can J Anaesth. 1998;45:612–619. 9. Fischer JP, Wes A, Nelson JA, et al. Factors associated with readmission following plastic surgery- a review of 10,669 procedures from 2011 American College of Surgeons Nation Surgery Quality Improvement Project (ACS-NSQIP) dataset. Plast Reconstr Surg. 2013;132:666–674. 10. Fleisher LA, Pasternak LR, Lyles A. A novel index of elevated risk of inpatient hospital admission immediately following outpatient surgery. Arch Surg. 2007;142: 263–268. 11. Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg. 1997;84:319–324. 12. Mezei G, Chung F. Return hospital visits and hospital readmissions after ambulatory surgery. Ann Surg. 1999;230:721–727. 13. Warner MA, Shields SE, Chute CG. Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA. 1993;270:1437–1441. 14. Keyes GR, Singer R, Iverson RE, et al. Mortality in outpatient surgery. Plast Reconstr Surg. 2008;122:245–250. 15. Pannucci CJ, Shanks A, Moote MJ, et al. Identifying patients at high risk for venous thromboembolism requiring treatment after outpatient surgery. Ann Surg. 2012;255: 1093–1099. 16. Pugely AJ, Martin CT, Gao Y, et al. Outpatient surgery reduces short-term complications in lumbar discectomy: an analysis of 4310 patients from the ACSNSQIP database. Spine (Phila Pa 1976). 2013;38:264–271. 17. Khavanin N, Mlodinow A, Milad MP, et al. Comparison of perioperative outcomes in outpatient and inpatient laparoscopic hysterectomy. J Minim Invasive Gynecol. 2013; 20:604–610. 18. Stack BC Jr, Moore E, Spencer H, et al. Outpatient thyroid surgery data from the University Health System (UHC) Consortium. Otolaryngol Head Neck Surg. 2013;148: 740–745. 19. Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules; Final Rule Federal Register / Vol. 78 , No. 17 / Friday, January 25, 2013 / Rules and Regulations. Available at: http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/ html/2013-01073.htm. Accessed November 14, 2013. 20. AAAHC. Accreditation Guidebook for Office Based Surgery. Skokie, IL: AAAHC: 2011;34–36. 21. Lawson EH, Louie R, Zingmond DS, et al. A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications. Ann Surg. 2012;256:973–981. 22. Schwulst SJ, Mazuski JE. Surgical prophylaxis and other complication avoidance care bundles. Surg Clin North Am. 2012;92:285–305. 23. Raval MV, Hamilton BH, Ingraham AM, et al. The importance of assessing both inpatient and outpatient surgical quality. Ann Surg. 2011;253:611–618. 24. Everett L, Glass P. The SAMBA nical Outcomes Registry: description of the first 20,000 cases. American Society of Anesthesiologists Annual Meeting Abstracts, 2012, A059. 25. Polaner DM, Taenzer AH, Walker BJ, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012;115:1353–1364. 26. Couloures KG, Beach M, Cravero JP, et al. Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics. 2011;127:e1154–e1160. www.anesthesiaclinics.com

Quality management in outpatient surgical care.

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