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Hamilton Eye Institute Surgery Center LP

930 Madison Ave, Suite 370
Memphis, Tennessee 38163

Survey Submission Date: June 27, 2024

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Patient Safety

Patient Rights and Ethics

Measure name	Leapfrog’s Standard	Progress Towards Meeting Leapfrog’s Standard
Billing Ethics	Surgery centers should publish prices, and provide patients with complete billing information and access to a representative that can quickly resolve billing issues. In addition, surgery centers should not sue patients over late or unpaid bills. more	SOME ACHIEVEMENT
	Show more on this surgery center’s performance Show less This surgery center does not publish pricing information for common procedures. This surgery center provides a detailed bill within 30 days of receiving insurance payments: Only upon request This surgery center provides access to a representative who can quickly investigate billing errors and establish payment plans: Yes This surgery center sues patients: No
Health Care Equity	Surgery centers should examine their own data to identify any differences in processes or outcomes for patients of different races and ethnicities, and patients who speak different languages. Surgery centers should also put action plans in place if differences are identified. more	LIMITED ACHIEVEMENT
Informed Consent	Surgery centers should ensure that all patients are fully aware of risks and alternatives prior to procedures. more	CONSIDERABLE ACHIEVEMENT
	Show more on this surgery center’s performance Show less All staff involved in the informed consent process achieve the appropriate training: Yes Doctors explain expected difficulties and recovery time and allow patients to ask questions: Yes Doctors involved in the procedure are listed on the consent form, and patients are notified if the doctor will be absent and if trainees will be involved: Yes Consent forms are written at a 6th grade reading level: No, all forms are at a 9th grade reading level or lower Staff ask patients about their preferred language for decision-making and make a trained medical interpreter available if appropriate: Yes Doctors use the "teach back method" to ensure patients understand what will be performed and what are the risks: Yes
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. more	ACHIEVED THE STANDARD

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Protocol to collect and respond to patient-reported concerns about care

This surgery center does have a protocol to collect and respond to patient-reported concerns about care.

Preventing Patient Harm

Measure name

Leapfrog’s Standard

Progress Towards Meeting Leapfrog’s Standard

Percentage of Registered Nurses (RNs) who have a Bachelor’s Degree in Nursing

Surgery centers should have a high proportion of highly trained and skilled registered nurses (RNs) who have an advanced nursing degree.

CONSIDERABLE ACHIEVEMENT

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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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.

ACHIEVED THE STANDARD

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Staff Identify and Mitigate Risks Associated with Errors

Surgery centers should use retrospective and prospective data sources, including patient reports, to identify and mitigate errors that harm patients including medication errors and infections.

ACHIEVED THE STANDARD

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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, offer training and education, and have provided equipment, such as paper towels, soap dispensers, and hand sanitizer.

ACHIEVED THE STANDARD

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Healthcare-Associated Infections

Measure name	Leapfrog’s Standard	Progress Towards Meeting Leapfrog’s Standard
Tracking and Reporting Accidents and Infections	Surgery centers should track and report all applicable accidents such as burns, falls, errors, surgery center admissions and surgical site infections, to a national database. more	ACHIEVED THE STANDARD

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.

ACHIEVED THE STANDARD

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Surgery

Complex Adult Surgery

Measure name	Leapfrog’s Standard	Progress Towards Meeting Leapfrog’s Standard
Total Knee Replacement Surgery	Surgery centers should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	DOES NOT APPLY
Total Hip Replacement Surgery	Surgery centers should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	DOES NOT APPLY

Elective Outpatient Surgery - Adult

Ophthalmology (Eyes)

Procedure	Number of Procedures Performed Annually
Anterior Segment Eye Procedures	449
Posterior Segment Eye Procedures	1,187
Other Eye Procedures	610

Otolaryngology (Ear, Nose, Mouth, and Throat)

Procedure	Number of Procedures Performed Annually
Ear Procedures	0
Mouth Procedures	0
Nasal and Sinus Procedures	12

Plastic and Reconstructive Surgery

Procedure	Number of Procedures Performed Annually
Breast Repairs and Reconstructions	0
Skin Grafts and Repairs	113

Elective Outpatient Surgery - Pediatric

Ophthalmology (Eyes)

Procedure	Number of Procedures Performed Annually
Other Eye Procedures	60

Otolaryngology (Ear, Nose, Mouth, and Throat)

Procedure	Number of Procedures Performed Annually
Ear Procedures	0
Mouth Procedures	0
Nasal and Sinus Procedures	4
Pharynx, Adenoid, and Tonsil Procedures	0

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 is present and immediately available while an adult patient is present until discharge.

ACHIEVED THE STANDARD

Elective Outpatient Surgery Recovery Staffing - Pediatric

Surgery centers should ensure that a specially certified clinician is present and immediately available while pediatric patient is present until discharge.

ACHIEVED THE STANDARD

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

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.

LIMITED ACHIEVEMENT

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Unplanned Hospital Visits after Colonoscopy

Unplanned hospital visits can occur when patients experience complications after a colonoscopy procedure. Facilities should have a rate of unplanned hospital visits that is lower than most hospitals and surgery centers.

DOES NOT APPLY

Unplanned Hospital Visits after Orthopedic Procedures

Unplanned hospital visits can occur when patients experience complications after an orthopedic procedure. Facilities should have a rate of unplanned hospital visits that is lower than most surgery centers.

DOES NOT APPLY

Unplanned Hospital Visits after Urology Procedures

Unplanned hospital visits can occur when patients experience complications after a urology procedure. Facilities should have a rate of unplanned hospital visits that is lower than most surgery centers.

DOES NOT APPLY

Hamilton Eye Institute Surgery Center LP

930 Madison Ave, Suite 370
Memphis, Tennessee 38163

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