Healthcare compliance changes medicare

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The new quality assurance program was to involve all departments and services, not just a quality assurance unit. It was to be problem-focused rather than mindlessly to collect vast quantifies of data for their own sake, which the old medical audit standard had encouraged. The new standard was approved in but not implemented until , to give hospitals time to develop systematic quality assurance programs. The standards should be statements of objectives, leaving the means to achieve their intent to the discretion of individual hospitals.

The standards should focus on elements essential to high-quality patient care, including the environment in which that care is given. The standards for governing bodies, medical staffs, management and administrative services, medical records, and quality and appropriateness review for support services were revised first.

Despite the intention to simplify the standards and make them less prescriptive and more goal-oriented, the revision process ended up involving substantial expansion and formalization of quality assurance activities in each chapter of the hospital accreditation manual, including an increasing specification of processes needed to achieve the objectives of JCAH's new quality assurance standard.

In the new quality assurance chapter of the hospital accreditation manual had one standard: There shall be evidence of a well-defined, organized program designed to enhance patient care through the ongoing objective assessment of important aspects of patient care and the correction of identified problems.

According to a standard in the governing body chapter, the governing body was to hold the medical staff responsible for establishing quality assurance mechanisms. One of the medical staff standards required regular review, evaluation, and monitoring of the quality and appropriateness of patient care provided by each member of the medical staff as well as surgical case tissue review, review of pharmacy and therapeutic activities, review of medical records, blood utilization review, review of the clinical use of antibiotics, and participation in hospitalwide functions such as infection control, safety and sanitation, and utilization review.

In uniform language for the monitoring and evaluation of quality and appropriateness of care was added into each of 14 chapters on specific clinical services, e. The required characteristics of an acceptable process for carrying out the standard included: designation of the department head as responsible for the process, routine collection of data about important aspects of the care provided, periodic assessment of the data to identify problems or opportunities to improve care, use of objective criteria that reflect current knowledge and clinical experience, taking actions to address problems and document and report problems to the hospitalwide quality assurance program, and, finally, evaluating the impact of the actions taken JCAH, In , after four field reviews of several drafts, revised medical staff standards were included in the hospital accreditation manual but not used for accreditation decisions until The standard for medical staff monitoring and evaluation of the quality and appropriateness of patient care now included departmental review of the clinical performance of all individuals with clinical privileges and went on to specify the same required characteristics included in the other chapters on clinical services JCAH, a.

In the quality assurance chapter was revised to add three standards. The second standard codified the monitoring and evaluation functions already specified in the medical staff chapter and in each of the chapters on other services.

It mandated certain hospitalwide activities infection control, utilization control, and review of accidents, injuries, and safety hazards and required that the relevant findings of quality assurance activities were considered in the reappraisal or reappointment of medical staff members and renewal of clinical privileges of independent practitioners.

The third standard required the use of the same steps for carrying out monitoring and evaluation activities already listed as required characteristics in each of the clinical chapters in the manual. The fourth standard called for hospitalwide coordination and oversight of quality assurance activities JCAH, b see Table 7. By , then, an elaborate set of quality assurance processes had evolved as standards and required characteristics in every chapter of the hospital accreditation manual.

The object of these processes is aimed at making hospitals, through their medical staff, review and assess the quality of care given by each person with clinical privileges and in each clinical department and to act on problems or opportunities that are identified. Most hospitals, however, have had significant problems complying with the standards. As already noted, the quality assurance standard adopted in was not implemented until Even then, hospitals only had to comply with the first three steps: assignment of authority and responsibility for quality assurance activities to a specific individual or group; progress in coordinating existing quality assurance mechanisms; written plan JCAH, In more than 60 percent of the 12, contingencies given by JCAH to the 1, hospitals surveyed were for quality assurance problems.

The proportion of hospitals with contingencies or recommendations for credentialing was 63 percent and for surgical case review was 45 percent Roberts and Walczak, Despite compliance problems, JCAH increased the level of compliance required with the quality assurance standard during , requiring evidence that quality assurance information was being integrated, that patient care problems were being identified through the monitoring and evaluation activities of the medical staff and support services, and that the problems were being resolved JCAH, Medical staff quality assurance activities still accounted for a large proportion of the contingencies and recommendations given in , in areas such as the following: monthly department meetings to consider monitoring and evaluation findings 46 percent of hospitals surveyed ; medical staff monitoring and evaluation actions are documented and reported 44 percent ; and when important problems in patient care or opportunities to improve care are identified, problems are resolved 32 percent Longo et al.

In , JCAH introduced implementation monitoring, by which certain standards would be surveyed and recommendations made, but lack of compliance would not affect accreditation decisions. JCAH explained that some changes in standards were taking more than 3 years for full implementation because they were difficult for hospitals to meet and required more time for learning and for education of surveyors JCAH, Not surprisingly, most of the standards placed on implementation-monitoring status initially, from January through June , pertained to quality assurance: some parts of medical staff departmental monitoring and evaluation, use of medical staff quality assurance findings, and quality and appropriateness review in support services.

In early the Joint Commission again eased implementation of the quality assurance standards. It no longer gave contingencies if hospitals were using only generic rather than department-specific indicators in monitoring and evaluating the quality and appropriateness of care in the various departments and services. The explanation for the change in contingency policies referred to the problems the Joint Commission itself had encountered in developing quality indicators for various types of care: "As the Agenda for Change activities have moved forward, it has become evident that the clinical literature does not provide sufficient information to permit health care organizations to select a full set of validated indicators for each area of clinical practice" JCAHO, b, p.

The problems that many hospitals were having in complying with the Joint Commission standards for outcome-oriented monitoring and evaluating quality of care were part of the impetus for the Joint Commission effort, called the Agenda for Change, to develop indicators of organizational and clinical performance for the hospitals to use JCAHO, c, d, e.

The data on such indicators would be transmitted by each hospital to the Joint Commission for use in developing empirical norms for hospitals to use in comparing their performance. Eventually, such indicator data could be used by the Joint Commission for monitoring compliance with accreditation standards.

The quality assurance condition implemented in late by HCFA is similar in approach to, although less elaborate than, the Joint Commission's quality assurance standards. The task force of HCFA officials that developed the revised conditions in consciously tried to make the new requirements consistent with JCAH standards.

JCAH had revised and updated its standards continuously while Medicare had not. The task force stated: "Another recent consideration is the movement toward providing hospitals with greater flexibility in determining how they can best assure the health and safety of patients. The current regulations are, in many cases, overly prescriptive and not sufficiently outcome oriented. Task force members agreed that a quality assurance program aimed at the identification and correction of patient care problems should be a condition because it was important and cut across all aspects of direct patient care.

The task force suggested three minimal standards: 1 the organized, hospitalwide quality assurance program must be ongoing and have a written plan of implementation; 2 the hospital must take appropriate remedial action to address any deficiencies found; and 3 there must be evaluations of all organized services and of nosocomial infections, medicine therapy, and tissue removal.

The new quality assurance condition as finally promulgated calls for a formal, ongoing, hospitalwide program that evaluates all patient care services Table 7. The interpretive guide lines state that information gathered by the hospital to monitor and evaluate the provision of patient care should be based on criteria and measures generated by the medical and professional staffs and reflect hospital practice patterns, staff performance, and patient outcomes.

The term outcome does not appear in the language of the conditions or standards, however, because the majority of the task force did not think that outcome measures could be used in the survey process. The discussion in the task force report of the new condition pointed out that outcomes were difficult to use because of the differences in the pre-operative condition of patients.

Although outcome measures were desirable, because they promised maximum flexibility to hospitals, they were difficult to assess without undertaking longitudinal studies beyond the given episode of care, which would be too cumbersome for hospitals and surveyors and difficult to use in enforcement.

One objective of the revision of the Conditions of Participation was simplification of the regulations, and overlapping language in different conditions was usually eliminated. Accordingly, the monitoring and evaluation activities in each department and service implied by the quality assurance condition are not repeated under the other conditions, whereas the appropriate quality assurance standards are repeated in the various chapters of the Joint Commission's hospital accreditation manual and are cross-referenced with the quality assurance chapter.

There are few other references to quality in the other conditions. However, the governing body condition has a standard for ensuring that the medical staff is accountable for the quality of patient care, and the medical staff condition has a parallel standard: The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients.

The interpretive guidelines for the medical staff condition also require that periodic appraisals of staff include information on competence from the quality assurance program. The only other reference to the quality assurance program outside the quality assurance condition itself is in the infection control condition, where a standard assigns responsibility to the chief executive officer, medical staff, and director of nursing services to assure that hospitalwide quality assurance and training programs address problems identified by the infection control officers.

The revisions of the Conditions of Participation, including the new quality assurance condition, were based in pan on work done in the late s and very early s. They resemble the evolution of the JCAH standards in the same time period, when JCAH adopted a quality assurance standard and began to revise the other standards to make them more flexible and less prescriptive. However, the Joint Commission's standards have undergone substantial evolution since the early s.

The latter's quality assurance standard in particular has undergone a great deal of elaboration in the process of trying to help hospitals understand how to comply with its intent. Compliance with hospital regulatory standards is monitored and enforced through a process of on-site surveying by health professionals. The resources and procedures of Medicare and the Joint Commission for surveying are described and compared in this section.

Section of the Social Security Act directs the Secretary of DHHS to enter into agreements with any ''able and willing'' state, under which the state health department or other appropriate state agency surveys health facilities wishing to participate in Medicare and certifies whether they meet the federal Conditions of Participation and other requirements. In return, the secretary agrees to pay for the reasonable costs of the survey and certification activities of the state agency.

With very few exceptions, the same state agencies conduct state licensure and federal certification surveys of all health providers in their states, including nursing homes, laboratories, home health agencies, and hospitals.

Most of the state agency survey load consists of nursing homes, because they are much more numerous than hospitals but do not have Joint Commission deemed status. Funding for Medicare certification activities comes from the Medicare trust funds. HSQB estimates average survey costs by type of facility and allocates the funds to each federal regional office by its share of each type of facility.

Each regional office, however, uses a different method of distributing survey funds to the states. The states are also reimbursed for surveys of Medicaid facilities and use state funds for licensure activities. An Institute of Medicine IOM study of nursing home regulations in found great variation in state survey agency budgets and policies.

As a result, the number of surveyors and the intensity of the surveys, as measured by average person-days at a facility, varied tremendously IOM, Federal regulations and HCFA's state operations manual are very general regarding survey agency staffing levels and qualifications.

As a result, there are large state-to-state differences in the experience and educational backgrounds as well as numbers of the surveyors. This affects the composition of survey teams—e. Nationally about half are nurses, 20 percent are sanitarians, and most of the rest are engineers, administrators, and generalists DHHS, But in , eight states had only one or two licensed nurses on staff Association of Health Facility Licensure and Certification Agency Directors, Only a few state agencies have physicians on staff.

The Joint Commission has surveyors in its hospital accreditation program, 61 full-time, 74 part-time, and 55 consultants, who are based around the country JCAHO, f.

Most of the consultants are physician rehabilitation and psychiatric specialists who survey rehabilitation and psychiatric hospitals and those same services in general hospitals, if provided.

Joint Commission survey team composition for the typical general acute-care hospital is a physician, an administrator, a registered nurse, and a medical technologist. The survey team may be tailored for hospitals that offer psychiatric, substance abuse, or rehabilitation services by including or adding physician surveyors with the appropriate specialty to the team. In the Joint Commission adopted a formula for determining survey costs, which are paid by the hospital desiring accreditation.

The fee consists of a base fee and an additional charge that varies with the annual number of total patient encounters. In recent years, fees have amounted to about 70 percent of the Joint Commission's revenues; most of the rest is derived from the sale of publications and educational services. HCFA does not have a fixed survey cycle for hospitals.

Beginning in FY , state agencies were funded to survey percent of unaccredited hospitals currently, 75 percent. The visits are scheduled ahead of time. Once certified, a hospital stays certified until and if a subsequent survey finds it out of compliance with one or more conditions, which could be more than a year.

Until , hospitals meeting JCAH standards were accredited for 2 years or, if there were problems, 1 year. Since , a hospital found to be in substantial compliance with Joint Commission standards has been awarded accreditation for 3 years. The surveys are scheduled in writing at least 4 weeks ahead of time. Both state agency and Joint Commission surveyors use survey report forms.

State agency surveyors fill out survey forms provided by HCFA Form HCFA , which permit the surveyor to mark as "met" or "not met" each condition, each standard under a condition, and each element of a standard if specified in the regulations. Altogether more than items are checked as met or not met. The surveyors may refer to interpretive guidelines in the HCFA state operations manual HCFA, , which provide further guidance for evaluating compliance with the regulation condition, standard, or element but do not have force of law.

The interpretive guidelines also specify the survey procedures to be used in verifying compliance. For example, element 3 of the quality assurance standard, Clinical Plan, states: "All medical and surgical services performed in the hospital must be evaluated as they relate to appropriateness of diagnosis and treatment" see Table 7. The language is further explicated in the interpretive guidelines: "All services provided in the hospital must be periodically evaluated to determine whether an acceptable level of quality is provided.

The services provided by each practitioner with hospital privileges must be periodically evaluated to determine whether they are of an acceptable level of quality and appropriateness.

Determine that a review of medical records is conducted and that the records contain sufficient data to support the diagnosis and to determine that the procedures are appropriate to the diagnosis. The Joint Commission survey report forms one for each surveyor discipline, e. The scale goes from 1 for substantial compliance to 5 for noncompliance. To help the surveyors to determine the degree of compliance with an item, the Joint Commission has developed explicit scoring guidelines for most chapters in the hospital accreditation manual as well as for the monitoring and evaluation of quality and appropriateness of care in each of the clinical services chapters.

The scoring guidelines have been published and are available for sale to the hospitals. Table 7. If the standard or required characteristic receives a score of 3 for partial compliance, 4 for minimal compliance, or 5 for no compliance, the surveyor must document the findings on blank pages that face each page of items in the survey report form.

State agency and Joint Commission survey teams present their findings at exit conferences, and hospitals with significant problems may begin to make corrections to head off a possible decertification or nonaccreditation action. Some state surveyors obtain plans of correction at this time, whereas others ask for them after reviewing the findings at the office. Enforcement begins with a formal finding of noncompliance that necessitates correction. In both cases the facility may be and usually is certified or accredited on the basis of, or contingent on, a plan of correction that will, if carried out, bring the hospital into compliance.

Depending on the nature and seriousness of the problem, the state agency or the Joint Commission may require written documentation of corrective action or may decide to schedule an on-site visit by a surveyor to verify compliance. In most cases, enforcement ends when the plan of correction is carried out, and more formal enforcement action is rarely taken. In about 15 percent of the cases of the hospitals surveyed per year , problems are of a nature or degree of seriousness that an unaccredited hospital may be found out of compliance with a Condition of Participation, and decertification proceedings are begun.

If it is an "immediate and serious" deficiency, a fast-track termination process is triggered that results in decertification within 23 days.

In other cases, and in fast-track cases when the immediate jeopardy is removed, the process takes 90 days. In most cases, the hospitals move to make the changes necessary to have the proceedings dropped, but about 10 to 20 are terminated each year.

Traditionally, the Joint Commission has denied accreditation to between 10 and 15 hospitals a year about 1 percent of those surveyed. When the 3-year survey cycle with the contingency system was started in , about 15 percent of hospitals were accredited without contingencies and the rest, 83 to 84 percent, were accredited with contingencies that had to be removed within a certain time period, usually 6 months.

More recently, 99 percent of the accredited hospitals have been receiving contingencies, several hundred of them serious enough to trigger tentative nonaccreditation procedures, but, due to serious lags in computerizing the new procedures, only four lost accreditation in and five in Bogdanich, As a result, several hospitals with very serious problems identified in Joint Commission surveys were able to retain their accreditation status for months and even years.

Meanwhile, they had lost their Medicare certification as a result of validation surveys triggered by complaints. HCFA, in its state operations manual or otherwise, provides little guidance to the state agencies on how to decide whether the deficiencies found by surveyors amount to noncompliance with a Condition of Participation. For example, Hospital A may have deficiencies in four of the five standards comprising a condition but still be judged in compliance with the condition, whereas Hospital B may only have deficiencies in three standards and be ruled out of compliance with the condition.

The judgment is left to the state survey agency. In contrast, the Joint Commission has developed a complex algorithm for converting the scores on completed survey report forms for each standard and required characteristic into summary ratings on a decision grid sheet for each of the major performance-related functions that are taken into account in making accreditation decisions and decisions on whether to assign contingencies or not.

In some cases, such as medical staff appointment, clinical privileges, and monitoring functions e. In most cases, a set of scores of related items on the survey report form are aggregated according to specific written rules into a summary score. For example, the summary score for "evidence of quality assurance actions taken" is aggregated from some 21 scores on related items in 18 chapters of the accreditation manual. The accreditation decision grid, then, aggregates the hundreds of scores given by surveyors into 43 summary scores under 10 headings e.

Another 7 scores for standards on implementation monitoring status are listed but not used in making the accreditation decision. Another set of rules is then applied to determine whether the hospital should be accredited. This set of rules is also used to decide whether contingencies should be assigned, with what deadlines, and whether subject to a follow-up visit or just written documentation of corrective action.

For example, a tentative nonaccreditation decision is forwarded to the Accreditation Committee of the Joint Commission's board of commissioners if the four elements under the medical staff heading are scored 4 or 5, or five of the seven elements under the monitoring heading are scored 4 or 5, and so forth. Similarly specific rules determine whether 1 month, 3-month, 6-month, or 9-month.

These three sets of decision rules surveyor scoring of individual items on the survey report form, aggregation of the individual surveyor scores into summary scores on the accreditation grid sheet, and the rules used to make nonaccreditation and contingency decisions are new and constantly evolving as they are used in practice. They were adopted in response to complaints about variations in surveyor judgment and in Joint Commission decision making about accreditation; the advent of computers has made it possible.

Federal and Joint Commission efforts to develop and apply quality assurance standards are hampered in several ways. First, despite 70 years of efforts, we still do not have adequate and valid outcome standards.

Medicare and Joint Commission standard-setters therefore have tried to mandate quality assurance processes in which hospitals use indicators of quality—outcome-oriented if possible but usually process and even structural in nature—to examine quality of care.

However, few clinical indicators have been adequately validated through research. Even fewer indicators of the quality of organizational performance exist. Nevertheless, to the extent there is knowledge about how to improve quality or make quality assurance more effective, it should be reflected in the Medicare and Joint Commission standards and survey processes.

The second barrier to quality assurance through certification and accreditation is the limited surveillance capacity inherent in any system of periodic inspections. A 2 day visit every year or two limits the ability of even the best surveyors to see if the process of care conforms to standards of best practice in an adequate sample of cases, let alone to see what the outcomes were. This "distance" problem is another reason why the standard-setters have tried externally to impose quality assurance standards that make the hospital itself conduct such surveillance continuously after the inspectors leave Vladeck, A third impediment to using regulatory, or self-regulatory, standards to assure quality is the ambivalent attitude of Medicare officials, the state agencies that actually survey the facilities, and Joint Commission leaders toward the use of sanctions.

The raison d'etre of the Joint Commission is professional self-improvement Federal and state officials are primarily motivated by the desire to make Medicare benefits widely available, and they are also subject to political pressure to keep facilities open, if at all possible.

The only formal sanction is loss of formal certification or accreditation, a drastic step that officials are reluctant to take except in extreme cases. The due process protections of the legal system also discourage enforcement attempts, as do the difficulties of documenting quality problems more subtle than gross negligence or death.

Thus, for a variety of reasons, officials are very reluctant to take formal enforcement actions, especially to the extent of terminating a facility, preferring instead to work with substandard or marginal facilities over time and bring them into compliance.

This approach works well if the hospitals involved have the will and capacity to improve, if shown how to do it, but it is ill-equipped to deal with places that cannot or will not improve. Fourth, while the federal government has delegated much of the standard-setting and enforcement to private accreditation bodies on the one hand, it has given away much discretion to the states on the other. The states have always varied greatly in their interpretation of federal standards, and little has been done to increase consistency.

HCFA requirements for state survey programs are very loose. Federal officials recognized from the beginning that who does the surveying is critical, "since this greatly influences what the emphasis will be, regardless of what the standard-setters think the emphasis should be" Cashman and Myers, , p.

The development of interpretive guidelines and survey procedures for the new Conditions of Participation was a step in the right direction. HCFA could develop more sophisticated decision rules for state agencies to use in determining compliance and making enforcement decisions. It also could develop a more statistically credible survey validation program to check the performance of the Joint Commission and the states.

Many of the obstacles to more effective quality assurance facing HCFA's survey and certification and the Joint Commission's accreditation efforts are those facing Medicare's Utilization and Quality Control Peer Review Organizations PROs : lack of knowledge about the relations among structure, process, and outcome; distance; and political pressure. One of the advantages of the PRO program is its continuous access to information on individuals and the episodes of care they experience.

Unlike the survey agencies or the Joint Commission at least until and if its plan to develop and then collect data on clinical and organizational indicators is carried out , PROs can actively screen data using indicators of poor quality or inappropriate care. This at least allows them to identify statistically aberrant hospitals and physicians through the use of aggregate profiles.

However, the PROs are not well able to make the in-depth on-site investigations of places the indicators may identify, especially small, remote hospitals in rural areas. The survey agencies, on the other hand, can and do mandate certain minimum capacity characteristics of hospitals. In addition, they can require that hospitals have and use internal quality assurance standards and procedures.

They can require those specific process characteristics that research has or will show are associated with favorable outcomes. In the meantime, the standards should be periodically revised in accord with expert consensus about best practices. Finally, survey agencies could be involved formally and systematically in investigations of hospitals where PRO-derived quality indicators signal possible quality problems and could use their legal authority to mandate changes needed.

The Conditions of Participation and procedures for enforcing them are a part of the federal government's quality assurance effort, and, as such, they should be the best possible, given the state of current knowledge and availability of resources, and they should be consistent with and supportive of other federal quality assurance activities. If certification is considered to be an important part of the federal quality assurance effort, the standards Conditions of Participation should be revised to be consistent and supportive of the overall federal quality assurance effort and kept up-to-date.

HCFA should take a number of steps to increase enforcement capacity some of them already adopted in nursing home regulation , including the following: specification of survey team size and composition; use of survey procedures and instruments that focus more on patients and less on records; development of explicit decision rules for determining enforcement actions; adoption of intermediate sanctions, such as fines and bans on admissions, so the punishment can fit the crime; and more use of federal inspectors to evaluate state agency performance through validation surveys and to inspect state hospital facilities.

Deemed status should continue, and the Joint Commission should be encouraged in its efforts to develop a state-of-the-art quality assurance program, but, at the same time, federal oversight of the Joint Commission should be increased to ensure accountability and there should be more disclosure of information about hospitals with quality problems discovered by the Joint Commission.

HCFA should develop criteria and procedures for referring cases in which there are indications of serious quality-of-care problems from PROs to the Office of Survey and Certification and vice versa. About 7, hospitals provide services to Medicare patients. The Secretary of DHHS has the regulatory authority to promulgate standards called Conditions of Participation in order to assure the adequate health and safety of Medicare patients in those hospitals, although the 5, hospitals accredited by the private Joint Commission and the AOA are deemed to meet the federal standards without further inspection by a public agency except for a small number of accredited hospitals that are subject to validation surveys each year.

In effect, then, Joint Commission standards are the Medicare standards for most Medicare beneficiaries using hospital services. At the same time, the users of 1, hospitals rely on the standards in the Medicare Conditions of Participation. These are mostly small, primarily rural hospitals where Medicare beneficiaries do not have the alternative of going to an accredited hospital.

Both sets of standards, therefore, affect a large number of people and should be as effective as possible in achieving the goal of assuring adequate care. This chapter has examined the evolution of Medicare and the Joint Commission hospital standards from mostly structural standards aimed at assuring that a hospital has the minimum capacity to provide quality care to mostly process standards aimed at making hospitals assess in a systematic and ongoing way the actual quality of care provided on their premises.

Also, certain structural standards, such as those for fire safety, that continue to be mandated and enforced through the certification and accreditation standards may not be closely related to patient care but are important factors in patient safety.

The certification and accreditation programs are inherently limited in their capacity to assure quality of care. They are hampered by the lack of knowledge about the interrelations between structure and process features of a hospital and patient outcomes. They are limited because periodic inspections cannot reveal much about how well the process of care conforms to the standards of best practice, or what the outcomes of care are.

They rely on the subjective judgment of their inspectors and the enforcement attitudes of the inspection agencies. Certification and accreditation could play a significant role in Medicare's quality assurance efforts if several issues are addressed.

Pros and cons of suggested strategies are identified for consideration. Throughout this chapter, we use the terms nonaccredited and unaccredited. Nonaccredited hospitals are those that have lost accreditation from the Joint Commission. Unaccredited hospitals are those hospitals that have never been accredited by the Joint Commission or who were accredited but subsequently lost accreditation and are not actively pursuing accreditation with the Joint Commission. Another regulation automatically permits hospitals that meet the Medicare Conditions of Participation to participate in Medicaid.

One consumer representative has served on the board since In late , two more public members were added to the Joint Commission board. Most of the unaccredited hospitals had fewer than 25 beds and therefore were not eligible for accreditation under ACS rules at that time. At hearings on health services for the aged, HEW Secretary Ribicoff said he would ''hand down an order that any hospital that was accredited by the Joint Commission on Accreditation would be prima facie eligible" quoted in Jost, , p.

The report of the Senate Finance Committee accompanying the Medicare bill said that hospitals accredited by JCAH would be "conclusively presumed to meet all the conditions for participation, except for the requirement of utilization review" quoted in Worthington and Silver, , p.

Art Hess, first head of Medicare, told the American Public Health Association at its annual meeting that the Social Security Administration did not want to pay for services that did not meet "minimal quality standards," but "the intention Two special certification provisions were implemented in for certifying hospitals that did not meet the Conditions of Participation.

The access provision allowed for the certifying of rural hospitals out of compliance with one or more conditions but in compliance with all statutory provisions provided the hospital was located in a rural area where access by Medicare enrollees to fully participating hospitals would be limited. The second provision. Both provisions have since been terminated. As of , 98 hospitals that had applied in were still not in the program and hospitals were participating through the special access certification provision Worthington and Silver, JCAH apparently adopted the utilization review requirement implemented in in the hope that accredited hospitals could be deemed to meet all federal requirements without state agency inspection.

The Secretary of the DHHS, however, has never agreed to let this accreditation standard be deemed to meet the federal utilization review requirement. Even though compliance at the condition level may be similar, it is interesting to note that more detailed analyses in earlier reports found that only about 10 to 14 percent of the specific deficiencies cited were the same DHHS, , ; GAO, For example, comparative hospital mortality figures have no meaning without consideration of many factors such as case-mix, severity of illness, geographic differences, and patterns of care of the terminally ill among hospitals, hospices, nursing homes, and family homes.

As of late HCFA was considering a revision of its sampling methodology to improve the effectiveness of its validation efforts. Also, beginning in FY , the number of validation surveys performed by state agency staff was increased to approximately per year HCFA, personal communication, Turn recording back on.

Help Accessibility Careers. Search term. Michael G. McGeary Since the passage of Medicare legislation in , Section of the Social Security Act has stated that hospitals participating in Medicare must meet certain requirements specified in the act and that the Secretary of the Department of Health, Education and Welfare HEW [now the Department of Health and Human Services DHHS ] may impose additional requirements found necessary to ensure the health and safety of Medicare beneficiaries receiving services in hospitals.

TABLE 7. Hospital Standards: Origin And Development Private, voluntary efforts to improve the quality of care in hospitals by setting minimum, and later, optimum standards date from The number of accredited hospitals increased steadily, however; by nearly 3, hospitals met the Minimum Standard, which accounted for more than half the hospitals in the United States 5 The Minimum Standard emphasized basic structural characteristics considered to be essential to "safeguard the care of every patient within a hospital" Roberts et al.

Early Government Standards State licensing programs for hospitals were not common until the early s. Development Of The Medicare Conditions Of Participation, The drafters of the Medicare legislation were aware of the variability in the extent and application of state licensure standards.

Jcah And Medicare In , with its standards forming the basis for the hospital Conditions of Participation in the Medicare program, JCAH found that the federal government was "usurping" its traditional role of guaranteeing minimum hospital standards Roberts et al. Evolution Of The Hospital Conditions Of Participation, The final regulations on the original Conditions of Participation that were promulgated in late were basically the same as those issued earlier in the year, except they accorded deemed status to hospitals accredited by the AOA.

Standards In , at the time the Conditions of Participation were first drafted, Donabedian identified three aspects of patient care that could be measured in assessing the quality of care: structure, process, and outcome. Structure And Process Orientation Of Hospital Standards The original conditions of , and the JCAH standards they were based on, were almost exclusively based on structural aspects of patient care, because structural measures are the easiest for standard-setters to specify, for surveyors to assess, and for enforcers to use in justifying their actions.

Shift From Capacity Standards To Performance Standards In recent years, HCFA and the Joint Commission have tried to revise their standards in ways that would impel hospitals to examine and, hopefully, improve the quality of their organizational and clinical performance.

Evolution Of The Joint Commission's Quality Assurance Standards The shift from prescriptive to performance-oriented standards began at JCAH in , when the board of commissioners decided to replace the numerical medical audit requirement with a new quality assurance standard that mandated an ongoing, hospitalwide effort to monitor care, identify problems or ways to improve care, and resolve any problems Affeldt et al. The standards would be essential ones that any hospital should meet. The standards must be reasonable and surveyable.

The standards should reflect the current state of the art. Survey Process Compliance with hospital regulatory standards is monitored and enforced through a process of on-site surveying by health professionals. Surveyors And Survey Teams Section of the Social Security Act directs the Secretary of DHHS to enter into agreements with any ''able and willing'' state, under which the state health department or other appropriate state agency surveys health facilities wishing to participate in Medicare and certifies whether they meet the federal Conditions of Participation and other requirements.

Survey Procedures Both state agency and Joint Commission surveyors use survey report forms. Enforcement Procedures Enforcement begins with a formal finding of noncompliance that necessitates correction. Enforcement Criteria HCFA, in its state operations manual or otherwise, provides little guidance to the state agencies on how to decide whether the deficiencies found by surveyors amount to noncompliance with a Condition of Participation.

Issues And Options Major Issue 1: Role Of Certification In Quality Assurance The Conditions of Participation and procedures for enforcing them are a part of the federal government's quality assurance effort, and, as such, they should be the best possible, given the state of current knowledge and availability of resources, and they should be consistent with and supportive of other federal quality assurance activities.

Pros: A large number of hospitals 1, with a significant number of beds are outside the accreditation system, and they tend to be the only hospitals in their area.

The conditions mandate some important basic structure and process standards e. State health facility surveyors are useful for investigating the muses of indicators of poor quality revealed through surveillance of case statistics. The inherent limits on the ability of periodic facility inspections to find problems in the quality of patient care are too great compared to, say, a peer review approach to justify more investment in this approach. Quality-of-care problems in unaccredited hospitals could be effectively dealt with by the PROs or other programs based on systematic, ongoing review of cases.

Political pressures on state health agencies and HCFA to keep hospitals open, especially in rural areas, are too great. The need to keep PRO data confidential precludes coordination with the certification process; potential triggering of regulatory enforcement would poison the peer review process. Related issue: Improving the standards. Pros: The current conditions and related standards and elements were developed in the early s and do not reflect recent advances in measuring and assuring quality of care.

State licensure standards even for basic structural aspects of hospitals vary widely and certification assures conformity to a uniform set of standards. It is not realistic to expect that the conditions, which must go through the formal federal rule-making process, can be updated continuously.

Little or no relation has been shown between facility-based standards and quality of patient care. Related issue: Improving enforcement. Pros: Increasing competition and price regulation e. Enforcement can be increased through these kinds of federal actions, as has been done with certified nursing homes.

Major Issue 2: Role Of The Joint Commission In Assuring Quality Of Care For Medicare Patients Deemed status should continue, and the Joint Commission should be encouraged in its efforts to develop a state-of-the-art quality assurance program, but, at the same time, federal oversight of the Joint Commission should be increased to ensure accountability and there should be more disclosure of information about hospitals with quality problems discovered by the Joint Commission.

Pros: Joint Commission standards are higher and more up-to-date than the Conditions of Participation. Accreditation is a positive incentive that motivates hospitals to improve more than certification does or can the Joint Commission is planning to reinforce this by recognizing ''superior" hospitals. Joint Commission inspectors have better clinical credentials and make more consistent decisions.

The Joint Commission may achieve better compliance than the state agencies because accreditation is highly valued and the state agencies are hampered procedurally and politically e. The Joint Commission is planning voluntarily to release information to HCFA on hospitals with significant quality problems whose continued accreditation is conditional on major changes.

These would be the 7 to 8 percent of hospitals surveyed each year that trigger one or more of the Joint Commission's nonaccreditation decision rules. In any case, the Joint Commission is a private organization governed by associations of the providers it is regulating; its survey findings are confidential except in 13 states—e.

The Joint Commission is not publicly accountable and, therefore, responsibility for assuring the health and safety of Medicare beneficiaries should not be delegated to it. The Joint Commission is still relatively weak in enforcing environmental and life safety code standards. HCFA must maintain a certification program with adequate standards and sufficient capacity resources and procedures in any case, to deal with small and rural hospitals that are not accredited, and this program could and should be applied to all hospitals would still be encouraged to seek accreditation.

The resources for increasing federal oversight—more funding for more intensive state inspections, more federal inspectors to conduct validation surveys—would be better used elsewhere in the federal quality assurance program.

Pros: The quality-of-care screens used by PROs include only indicators of quality-of-care problems, and the actual role of a hospital in producing adverse indicators has to be investigated further before changes can be required or sanctions applied. In many cases, on-site surveys by health facility inspectors could usefully supplement central reviews of cases by PRO clinicians.

The state inspection agencies and federal regional offices, in turn, could alert PROs when they find hospitals with possible quality-of-care problems; the PROs could then initiate focused reviews to document process of care or patient-outcome problems, if any.

Most state inspection agencies do not have physician inspectors and some do not have that many nurses, which limits their capacity to look at quality of clinical care or to justify findings in court against a facility's physician consultants.

Any additional resources for handling quality-of-care problems should go to building up PROs or some other peer review-oriented mechanism. Concluding Remarks About 7, hospitals provide services to Medicare patients. References Affeldt, J. Evaluation and the Health Professions , Summary Report: Licensure and Certification Operations.

Baltimore, Md. Bogdanich, W. Wall Street Journal October 12, , pp. A1, A Cashman, J. American Journal of Public Health , While CMS removed the use of CMS developed training requirements, plan sponsors have discretion to include their own compliance program training requirement as part of their contracts with FDRs. Therefore, FDRs, such as healthcare providers, must review their plan sponsor contracts to determine if they must continue using CMS training materials or are subject to modified compliance training requirements.

For healthcare providers that continue to use CMS training materials, note that CMS updated its general compliance and fraud, waste, and abuse web-based online courses within its Medical Learning Network as of April Incorporating appropriate software tools into your compliance strategy will help streamline processes and serve as your first line of defense against these significant risks areas.

Contact us today for a quick demonstration of our compliance management software solution. Your email address will not be published. Post Comment. The First Healthcare Compliance solution has everything you need to get started.

It helps a practice become compliant on a very timely basis. Without this, it would have been a very extensive and intensive process. The First Healthcare Compliance solution is cost-effective and efficient.

All of the compliance materials are in one place. In an era of ever changing regulations, First Healthcare Compliance has given us the tools to seamlessly and efficiently stay on top of our compliance requirements. This allows us more time to focus on patient care and other aspects of practice management. Compliance in all areas always seemed to take a back seat to day to day operations. First Healthcare Compliance has developed a solution that easily brings any size office into compliance.

It gives me peace of mind. The First Healthcare Compliance solution offers a simple and effective centralized system to access and assemble our compliance data with minimal effort and maximum return. I highly recommend it! The solution has been a great help to our practice.

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This article is copyrighted strictly for Electronic Health Reporter. Illegal copying is prohibited. The aesthetics industry is constantly evolving, requiring you to keep up with trends. The White House has issued a proclamation from President Biden declaring November as Critical Infrastructure Security and Resilience Month — A month dedicated to raising awareness of the need to improve critical infrastructure and strengthening the resilience of critical infrastructure against physical and cyber threats.

Health problems periodically occur in a person, regardless of his age, social status, and gender. This guide addresses the increased demand for and benefits of expanding your virtual care options to help retain patients, cut down on hospital readmissions, and expand revenue opportunities. Under the changes, traditional Medicare coverage will kick in the month immediately after enrolling. An interim national health plan in New Zealand underscores the contribution of digital tools in allowing the health system to provide more care in homes and communities.

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See the top articles from:. Select your country:. Ransomware Hospitals This plan should include who will be responsible for providing the training, how often it will be conducted, and what topics will be covered. Additionally, regular training can help ensure that staff members are up-to-date on any changes to the requirements. Additionally, several private companies offer compliance training services. When completing the documentation for the Medicare application process, all information must be accurate.

These requirements are available on the CMS website. When applying to the Marketplace, there may be some cases where additional documentation is requested to verify the information provided on the application. This documentation can include tax forms, birth certificates, or other items depending on the state in which you apply. To make sure that your organization is staying compliant, you need to have a process in place to monitor the implementation of compliant practices. This process should include regular check-ins and audits to ensure that policies and procedures are being followed and that compliance risks are being managed effectively.

This could be something as simple as an anonymous hotline or an online form. Having this in place can help prevent compliance issues from happening in the first place. The Office of Inspector General OIG recommends that individual and small group practices have a baseline audit of their claim development and submission process.

These audits help to ensure compliance with Medicare standards and may be conducted by an outside party such as a billing company or consultant. And last but not least, you need to have a plan for dealing with any compliance issues that do arise.

This should include an investigation process as well as corrective action plans. By having all of these elements in place, you can help ensure that your organization is compliant with Medicare requirements. One of the most important requirements for Medicare compliance is continuous quality improvement.

You must have a system in place to track and trend data, identify issues and problems, and then put corrective action plans in place to address those issues. One of the most important things to remember regarding Medicare compliance is keeping your provider data up-to-date. PECOS supports the electronic Medicare enrollment process; you can use it to make changes to your provider enrollment record. In this step, healthcare providers of Medicare need to develop standards of conduct specific to Medicare billing and reimbursement practices.

Staff should be trained on these standards and held accountable for them. You should also perform regular auditing and monitoring functions to ensure compliance. If you discover any non-compliance, take corrective action immediately. This may include retraining staff, modifying procedures, or taking disciplinary action against employees who violate the standards. You should also report any instances of fraud or abuse to the proper authorities.

By taking these steps, you can help ensure that your organization complies with Medicare billing and reimbursement practices.