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Marianne Klaas, RN, MN, CHSP

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Title: No Slide Title Author: Shannon Wheeler and Victoria San Juan Last modified by: Swedish Medical Center Created Date: 2/21/1997 2:19:52 AM Document presentation ... – PowerPoint PPT presentation

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Title: Marianne Klaas, RN, MN, CHSP


1
Contract Management and Vendor
OversightRegulations and Management Oversight
  • Marianne Klaas, RN, MN, CHSP
  • Swedish Medical Center
  • Administrative Director
  • Accreditation, Safety, Injury Management, and
    Clinical Patient Relations

2
Acknowledgement
  • VHA Program 5/29/12
  • Sentara- Norfolk, Virginia
  • St. Lukess Boise, Idaho

3
Center for Medicare and Medicaid Services (CMS)
  • 482.12(e) Standard Contracted Services
  • The governing body must be responsible for
    services furnished in the hospital whether or not
    they are furnished under contracts.
  • The governing body must ensure that a contractor
    of services (including one for shared services
    and joint ventures) furnishes services that
    permit the hospital to comply with all applicable
    conditions of participation and standards for the
    contracted services.

4
CMS
  • The governing body has the responsibility for
    assuring that hospital services are provided in
    compliance with the Medicare Conditions of
    participation and according to acceptable
    standards of practice, irrespective of whether
    the services are provided directly by hospital
    employees or indirectly by contract.
  • The governing body must take actions through the
    hospitals QAPI program to assess the services
    furnished directly by hospital staff and those
    services provided under contract, identify
    quality and performance problems, implement
    appropriate corrective or improvement activities,
    and to ensure the monitoring and sustainability
    of those corrective or improvement activities.
    (See 482.21 QAPI.)

5
The Joint Commission
  • LD.04.03.09 Care, treatment, and services
    provided through contractual agreement are
    provided safely and effectively.

6
Contracted Services
  • The same level of care should be delivered
  • Governing Body / Leaders provide oversight
  • The contractual agreements are those for
    hospitals patients.
  • Contracts for consultation or referrals are not
    subject to the requirements in Standard
    LD.04.03.09.
  • The expectations for the performance of
    contracted services should reflect basic
    principles of risk reduction, safety, staff
    competence, and performance improvement.

7
Methods for Oversight
  • Leaders are expected to select the best methods
    for their hospital to oversee the quality and
    safety of services provided through contractual
    agreement.
  • Reviews
  • Direct observations
  • Audits
  • Incident reports
  • Periodic performance reports
  • Collection of efficacy data
  • Performance indicators
  • Staff input
  • Patient satisfaction surveys
  • Risk management

8
CMS- TJC Crosswalk
  • CMS 482.12 (e)(1) The governing body must ensure
    that the services performed under a contract are
    provided in a safe and effective manner.
  • (e)(2) The hospital must maintain a list of all
    contracted services, including the scope and
    nature of the services provided.
  • TJC LD.04.03.09 EP4 Leaders monitor contracted
    services by establishing expectations for the
    performance of the contracted services. Note 3
    The leaders who monitorare the governing body
  • EP2 The hospital describes, in writing, the
    nature and scope of services provided through
    contractual agreements
  • EP3 Designated leaders approve contractual
    agreements

9
Clinical vs. Non-Clinical
  • CMS 482.12 (e)(1) The governing body must ensure
    that the services performed under a contract are
    provided in a safe and effective manner.
  • (e)(2) The hospital must maintain a list of all
    contracted services, including the scope and
    nature of the services provided.
  • An inventory of contract services that affect the
    quality and safety of patient care (clinical and
    non-clinical) should be developed and maintained.
  • Using hospital defined Inclusion and Exclusion
    criteria to identify relevant contracts and
    include on the hospital's inventory ONLY those
    contract services that meet the Inclusion
    criteria.

10
Inclusion vs. Exclusion Criteria
  • Inclusion Criteria Those contract services that
    contribute to the quality and safety of care,
    treatment and services including contract
    services with staff associated. Examples
  • Clinical Care
  • Medication Management
  • Physician Services (patient care)
  • Purchased Labor (patient care)
  • Affiliation Agreements (patient care)
  • Translation Services (Deaf
  • Talk/Interpretation Services)
  • Entire Department Contracted
  • Exclusion Criteria Those contract services that
    do not contribute to the quality and safety of
    care, treatment and services. Examples
  • Cable TV
  • Vending/ATMs
  • Lawn Services and Maintenance of Plants/Flowers
  • Lease agreements

11
TJC- LD 04.03.09
12
LD.04.03.09 EP1- 4Contracted Services
  • 1-Clinical leaders and medical staff advise on
    the sources of clinical services to be provided
    through contractual agreement.
  • 2 - The hospital describes the nature and scope
    of services provided through contractual
    agreements.
  • 3 - Designated leaders approve contractual
    agreements.
  • 4 - Leaders monitor contracted services by
    establishing expectations for the performance of
    the contracted services.
  • Note 1 In most cases, each licensed independent
    practitioner providing services through a
    contractual agreement must be credentialed and
    privileged by the hospital using their services
    following the process described in the Medical
    Staff (MS) chapter.
  • Note 3 The leaders who monitor the contracted
    services are the governing body.

13
LD.04.03.09 EP 5-7Contracted Services
  • 5 Leaders monitor contracted services by
    communicating the expectations in writing to the
    provider of the contracted services.
  • Note A written description of the expectations
    can be provided either as part of the written
    agreement or an addendum.
  • 6 - Leaders monitor contracted services by
    evaluating these services in relation to the
    hospital's expectations.
  • 7 - Leaders take steps to improve contracted
    services that do not meet expectations.
  • Examples of improvement efforts to consider
    include the following
  • Increase monitoring of the contracted services.
  • Provide consultation or training to the
    contractor.
  • Renegotiate the contract terms.
  • Apply defined penalties.
  • Terminate the contract.

14
LD.04.03.09 EP 8-10Contracted Services
  • 8 When contractual agreements are renegotiated
    or terminated, the hospital maintains the
    continuity of patient care.
  • 10 - Reference and contract laboratory services
    meet the federal regulations for clinical
    laboratories and maintain evidence of the same.
  • For law and regulation guidance on the
    Clinical Laboratory Improvement Amendments of
    1988, refer to 42 CFR 493.

15
LD.04.03.09 EP 23Contracted Services
(Telemedicine)
  • 23 - For hospitals that use Joint Commission
    accreditation for deemed status purposes The
    originating site has a written agreement with the
    distant site that specifies the following
  • The distant site is a contractor of services to
    the hospital.
  • The distant site furnishes services in a manner
    that permits the originating site to be in
    compliance with the Medicare Conditions of
    Participation (Appendix A)
  • The originating site makes certain through the
    written agreement that all distant site
    telemedicine providers credentialing and
    privileging processes meet, at a minimum, the
    Medicare Conditions of Participation at 42 CFR
    482.12(a)(1) through (a)(9) and 482.22(a)(1)
    through (a)(4). (See also MS.13.01.01, EP 1)
  • If the originating site chooses to use the
    credentialing and privileging decision of the
    distant-site telemedicine provider, then the
    following requirements apply
  • The governing body of the distant site is
    responsible for having a process that is
    consistent with the credentialing and privileging
    requirements in the Medical Staff (MS) chapter
    (Standards MS.06.01.01 through MS.06.01.13).
  • The governing body of the originating site grants
    privileges to a distant site licensed independent
    practitioner based on the originating sites
    medical staff recommendations, which rely on
    information provided by the distant site.

16
Det Norske Veritas (DNV)
17
DNV
18
DNV
19
DNV
20
So Easy? So Far From It!
21
Oversight Issue 1
  • Contracted Services own accreditation and
    certification
  • Validate currency
  • Meets all applicable standards

22
Oversight Issue 2
  • Direct Observation
  • After hours
  • Weekends

23
Oversight Issue 3
  • Documentation Audits
  • Vendor may use different forms
  • Vendor may lack details/specific for tracking and
    tracing
  • Vendor may not have access to electronic medical
    record
  • Vendor forms may be scanned into the record
  • Not documented, not done

24
(No Transcript)
25
Oversight Issue 4
  • Incident Reporting Structure
  • If asked to produce any incident reports based on
    contractor/vendor, could you?
  • Role of risk management
  • How can staff/medical staff report issues for
    tracking and trending? (ends up via QAPI)

26
Oversight Issue 5
  • Timely reviewing of periodic reports submitted by
    the individual or organization providing the
    services

27
Oversight Issue 6
  • Trust but verify that the organization is
    collecting data that addresses the service
    efficacy.

28
Oversight Issue 7
29
Oversight Issue 8
  • Human Resources Monitoring contracted services
    can be challenging because people doing the work
    are not direct employees of the organization.
  • COMPETENCY!
  • Trust but verify

30
Oversight Issue 9
  • Sub-contracting
  • No contractor should be sub-contracting their
    work without your express consent and knowledge.
  • Sub-contractors must meet same performance
    metrics.
  • Audit for any variances e.g., a different
    dialysis machine suddenly shows up (substituted)
    from a sub-contracted vendor.

31
Oversight Issue 10
  • Review patient satisfaction surveys

32
Bottom Line
  • Highly regulated
  • Specifics for being compliant
  • Daunting scope
  • Quality and patient care at stake
  • Financial gains possible (reducing contracts
    patient satisfaction)

33
Thank you!
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