On March 4, Texas Ambulatory Surgery Center Society members attended a virtual town hall, in order to learn best practices on proper incident reporting to Texas Health and Human Services.  

Laura Schneider  RN, Sr. Director of Clinical Services for Amsurg, began by reviewing the requirements of ASC Incident Reporting:

• ASCs must report required incidents within 10 business days
• The following incidents must be reported:

1. The death of a patient while under the care of the ASC
2. The transfer of a patient to a hospital
3. Patient development of complications within 24 hours of discharge from the ASC, resulting in admission to a hospital
4. A patient stay exceeding 23 hours
5. Any theft of drugs and/or diversion of controlled drugs
6. Abuse and neglect
7. Illegal, unprofessional or unethical conduct that relates to the operation of the facility or its services

Because of COVID, there have been compliance guidance letters from the state. Most recently, until March 21, 2021, centers do not need to report the transfer of a patient to a hospital or a patient stay exceeding 23 hours. However, ASCs must continue to report the death of a patient while under the care of the ASC and patient development of complications within 24 hours of discharge from the ASC, resulting in admission to a hospital.

The most current form, 6110, is two pages and is easily editable or can be filled out in writing. The state site also has a form available through their online portal, TULIP. However, Schneider mentioned that both forms are acceptable. If providing the 6110 form, it should be submitted to [email protected].

Schneider proceeded to review the form with the group, particularly the incident summary, which includes:

• A brief summary of the incident (what happened, who was involved and what action was taken when the incident occurred)
• If the patient received any treatment
• A narrative report of the investigation (how the incident was handled and what actions will be taken to reduce the potential of similar incidents in the future)
• An action to be taken as a result of this incident (while multiple options can be selected, Schneider’s centers action most often selected is Measure, Analyze and Track in Quality Assessment and Performance Improvement.

Schneider then introduced Chris Kralik, Administrator for both Digestive Health Centers of Plano and Allen. Kralik had five different examples of reports that he has filed for his ASCs and the different data provided in each scenario.

In one example, the incident was the development of complications within 24 hours of discharge, resulting in a hospital admission. Before the deadline of 10 business days, Kralik retrieved the hospital report and included treatment the hospital provided. He stated that in cases he cannot retrieve the report before the deadline, then, at a minimum, it should include what happened at the surgery center only. He further suggested to only use the hospital information for your own risk management, unless the state is asking for more details.

As part of risk management, a practice for Kralik’s facilities is to always request the information from the hospital, even if it is received after the incident reporting deadline. It may require multiple calls and follow up, but is important information to assess future preventable measures. Sometimes you’re reporting an incident that doesn’t have any actionable items, because the patient could have been admitted to the hospital that’s in no relation to the procedure at the facility. However, it still needs to be reported.

A takeaway from Kralik’s examples was the extent of information you’re including in the report.

• It’s good to be detailed but not necessarily as detailed as you would in a chart or nursing note
• Keep it short and sweet
• It’s not necessary to include provider names in the narrative
• Consider what a surveyor would be looking for

If for any reason you are missing information or the state needs more clarification, they will call or email you. This should not be something you are nervous about, as they are not looking for anything punitive. They are just reporting trying to obtain all needed information on the incident. 

Schneider mentioned in pre-COVID days, the state would come to the center and ask to see the charts (a practice that will likely resume when safe to do so). As a best practice, she suggests putting a copy of the chart with the incident report. That way when a surveyor comes, the reported information is readily accessible. Kralik further suggested to keep a digital copy, should it need to be corrected, and a hard copy. At his centers, he keeps a binder for each type of incident reported and a log of the incidents in the front of the binder. This also helps during a surveyor visit.

If you have additional thoughts on the topic of incident reporting, leave a comment below. If you have questions for the speakers, feel free to reach out: 

Laura Schneider RN, CGRN, CASC
Sr. Director, Clinical Services, AMSURG
[email protected] 972.284.7238 

Chris Kralik, BSN, RN, CGRN
Center Administrator, Digestive Health Center of Plano/Digestive Health Center of Allen
[email protected] 972-985-2300