Germantown Surgery Center Methodist LP
Germantown, Tennessee 38138
Preventing and Responding to Patient Harm
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Effective Leadership to Prevent Errors |
Surgery centers should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety. |
 ACHIEVED THE STANDARD |
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This surgery center scored 120.00 out of 120.00 possible points. |
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| Staff Work Together to Prevent Errors |
Surgery centers should have assessed their culture of safety and held leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety. |
 CONSIDERABLE ACHIEVEMENT |
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This surgery center scored 106.67 out of 120.00 possible points. |
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| Handwashing |
Surgery centers should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Surgery centers foster a culture of good hand hygiene, offers training and education, and have provided equipment, such as paper towels, soap dispensers, and hand sanitizer. |
 SOME ACHIEVEMENT |
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| Responding to Never Events |
Surgery centers should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. |
ACHIEVED THE STANDARD |
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| Tracking and Reporting Accidents and Infections |
Surgery centers should track and report all applicable accidents such as burns, falls, errors, hospital admissions and surgical site infections, to a national database. |
ACHIEVED THE STANDARD |
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Medication Safety
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Medication Documentation for Elective Outpatient Surgery Patients |
Surgery centers should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record. |
CONSIDERABLE ACHIEVEMENT |
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Elective Outpatient Surgery - Adult
Dermatology (Skin)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Complex Skin Repairs | 42 |
Gastroenterology (Stomach and Digestive)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Lower GI Endoscopies | 0 | |
| Other Upper GI Procedures | 1 | |
| Small Intestine and Stomal Endoscopies | 0 | |
| Upper GI Endoscopies | 0 |
General Surgery
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Cholecystectomies and Common Duct Explorations | 65 | |
| Hemorrhoid Procedures | 18 | |
| Inguinal and Femoral Hernia Repairs | 47 | |
| Laparoscopies | 59 | |
| Lumpectomies and Quadrantectomies of Breast | 373 | |
| Mastectomies | 29 | |
| Other Hernia Repairs | 72 |
Obstetrics and Gynecology
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Cervix Procedures | 11 | |
| Hysteroscopies | 116 | |
| Uterus and Adnexa Laparoscopies | 80 |
Ophthalmology (Eyes)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Anterior Segment Eye Procedures | 1,026 | |
| Posterior Segment Eye Procedures | 0 | |
| Other Eye Procedures | 119 |
Orthopedic (Bones and Joints)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Finger, Hand, Wrist, Forearm, and Elbow Procedures | 97 | |
| General Orthopedic Procedures | 14 | |
| Hip Procedures | 4 | |
| Knee Procedures | 75 | |
| Shoulder Procedures | 123 | |
| Spine Procedures | 5 | |
| Toe, Foot, Ankle, and Leg Procedures | 185 |
Otolaryngology (Ear, Nose, Mouth, and Throat)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Ear Procedures | 60 | |
| Mouth Procedures | 15 | |
| Nasal and Sinus Procedures | 1,384 |
Plastic and Reconstructive Surgery
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Breast Repairs or Reconstructions | 499 | |
| Skin Grafts and Repairs | 252 |
Urology (Urinary Tract, Male Reproductive)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Circumcisions | 1 | |
| Cystourethroscopies | 24 | |
| Male Genital Procedures | 5 | |
| Urethra Procedures | 4 | |
| Vaginal Repair Procedures | 1 |
Elective Outpatient Surgery - Pediatric
Orthopedic (Bones and Joints)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Finger, Hand, Wrist, Forearm, and Elbow Procedures | 3 | |
| General Orthopedic Procedures | 0 | |
| Hip Procedures | 0 | |
| Knee Procedures | 5 | |
| Shoulder Procedures | 2 | |
| Spine Procedures | 0 | |
| Toe, Foot, Ankle, and Leg Procedures | 6 |
Otolaryngology (Ear, Nose, Mouth, and Throat)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Ear Procedures | 318 | |
| Mouth Procedures | 2 | |
| Nasal and Sinus Procedures | 110 | |
| Pharynx, Adenoid, and Tonsil Procedures | 194 |
Care for Elective Outpatient Surgery Patients
| Measure name | Leapfrog’s Standard | Progress Towards Meeting Leapfrog’s Standard | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Elective Outpatient Surgery Recovery Staffing - Adult |
Surgery centers should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while an adult patient is present until discharge. |
SOME ACHIEVEMENT |
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| Elective Outpatient Surgery Recovery Staffing - Pediatric |
Surgery centers should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge. |
SOME ACHIEVEMENT |
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| Safe Surgery Checklist - Elective Outpatient Surgery |
Surgery centers should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed. |
ACHIEVED THE STANDARD |
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| Experience of Patients Undergoing Elective Outpatient Surgery |
Surgery centers should perform better than most on four (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients willingness to recommend the facility. |
ACHIEVED THE STANDARD |
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Performance on the following four domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey make up a hospital’s score on Leapfrog’s “Experience of Patients Undergoing Elective Outpatient Surgery” measure. “Top Box Score” represents the percentage of respondents who gave the most favorable response.
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More Information
| Patient Consent for Elective Outpatient Surgery |
The surgery center provides written surgical consent forms the day of their procedure. |
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| Patient Consent to Anesthesia for Elective Outpatient Surgery |
The surgery center provides written anesthesia consent forms the day of their procedure. |
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| Patient Selection |
The surgery center has a screening protocol to determine whether a patient’s procedure can safely be performed on an outpatient basis, and the protocol includes the following components:
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| Board Certification - Physician |
Most (>=75%) physicians at this surgery center who are authorized to perform procedures are board certified or board eligible. |
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| Board Certification - Anesthesiologist |
Most (>=75%) of those providing anesthesia at this surgery center who are authorized to perform procedures are board certified or board eligible. |
Germantown Surgery Center Methodist LP
1363 S Germantown Rd
Germantown, Tennessee 38138
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