problematic accreditation standards and what they … · problematic accreditation standards and...
TRANSCRIPT
Jon Burroughs, MD, MBA, FACHE, FACPE
May 28, 2013
Washington Association of Medical Staff Services Lake Chelan, Washington
Problematic Accreditation Standards and what they mean
CMS Conditions of Participation (CoP)
• Public process with comment period entered
into the federal registry
• CoPs trump all accreditation standards
• CMS surveys performed by state agencies
and public health departments
• Surveys generally ‘for cause’ and not random
with few physician surveyors (5%)
General Principles:
1. Physicians and management should interpret
CoPs and accreditation standards together
2. Interpretation should make clinical and
operational sense
3. If it doesn’t provide better patient care and
simplify your processes (cost less money) you
haven’t interpreted them the right way!
CoP Traditional Challenges:
• Medical history and physical examination
• Updated exam and chart entries
• Verbal orders
• Date, time and authentication of written orders
• Informed consent
• Discharge process and summary
• Completion of medical records
§482.22(c)(5): History and Physical
• Must be completed and documented for a
patient no more than 30 days before or 24
hours after admission or registration
• Must be completed by a physician (MD/DO,
DDS/DMD, DPM, DO, DC), oro-maxillofacial
surgeon, or other qualified licensed provider in
accordance with state law and hospital policy
Issues:
• Timely communication of essential clinical
information
• Accuracy of clinical information to justify coding,
billing and collections (fraud and abuse)
• Who is/are the most cost effective individual(s)
to do this work?
§482.22(c)(5): Updated Entries:
• An updated examination , including any
changes in the patient’s condition must be
documented within 24 hours after registration
or admission but prior to an operation or
procedure requiring anesthesia services
• Must indicate “no change” if there are no
interval changes in exam or condition
Issues:
• Timely communication of essential interval
clinical information that may have an impact
• Accuracy of clinical information to justify coding,
billing and collections (fraud and abuse),
particularly length of stay and status (e.g.
observation)
• Who is/are the most cost effective individual(s)
to do this work?
§482.23(c)(2)(i): Verbal Orders
• Verbal orders, if used, must be used infrequently.
• Only used to meet the care needs of the
patient….when it is impossible or impractical for the
ordering practitioner to write the order or enter it into a
computer…without delaying treatment
• Not to be used for…convenience
• CMS expects nationally accepted “read back”
verification process
• Verbal orders must be authenticated within 48 hours
(482.24(c)(1)(iii) (overturned in 2012)
Issues:
• Inaccuracy of verbal orders (5% failure rate!)
• Inadvertent errors and harm (e.g. dilaudid 2mg)
• Inadvertent orders to individuals unauthorized
to take them (technicians, LPNs etc.)
• What are viable ways to eliminate all verbal
orders?
§482.24(c)(1): Date, Time, and
Authentication of Written Orders
• All patient medical record entries must be
legible, complete, dated, timed and
authenticated in written or electronic form by
the person responsible for providing or
evaluating the service provided….
Rationale:
• Legible (avoid inadvertent errors)
• Complete (incomplete if does not identify the
patient, support the diagnosis/condition, justify the
care, document results of care, and promote
continuity of care)
• Date and time (documents timeline for critical
clinical decisions regarding medications and
treatment options)
• Authenticated (check for inaccuracies)
Issues: • Impossible to implement 100% (intentional!)
• Cannot use a rubber stamp
• Pre-printed order sets and documentation must
be updated to ensure accuracy and to avoid
fraud and abuse (corporate compliance)
• May require “back up” licensed personnel to
support (hospitalists, AHPs etc.)-nurses cannot
under state law!
• Dependent on an EMR and CPOE (that was the
intent!)
§482.24(c)(2)(v): Informed Consent
Required elements:
• Place of procedure
• Name of procedure
• Name of responsible practitioner(s)
• Determination of material risks, benefits, and
alternatives (must be provided by the practitioner
performing the procedure!)
• Signature/date/time entered by patient or legal
representative
Issues: • Only the operating physician/practitioner
understands the nature of the potential risks
and benefits
• Must communicate reasonable alternatives and
options!
• Must communicate others who will perform
important functions (residents, assistants,
anesthesia etc.)
• Cannot be delegated to nursing (state law)
• Other portions of this process may be
delegated!
§482.24(c)(2)(vii): Discharge Summary
• The MD/DO or other authorized LIP must
complete the discharge summary
• May be delegated to AHP (APP) under state
law and hospital policy
• For observation admissions under 48 hours, the
final progress note may constitute the discharge
summary as long as includes: outcome,
disposition, and provisions for follow up care
§482.24(c)(2)(viii): Completion of
Medical Records
• Final diagnosis with completion of medical
record within 30 days following discharge
• Rationale: Communication of critical information
to other physicians and care givers
• Avoidance of potential errors
• RAC issues for both organization and
physician!
2012 CoP Contemporary Challenges:
• Single governing board and medical staff
• Medical staff member on governing board
• Non-physicians on the medical staff
• Podiatrists as medical staff leaders
• Self-administered medications
• Standing orders
• Verbal orders update
§482.12: Single Governing Board
§482.22: Single Medical Staff
• May have a single governing board for each
hospital, one for the system as a whole, or a
corporate board with advisory boards for each
hospital
• Must have a single medical staff for each
hospital
• There is an opportunity to standardize medical
staff structures and processes, even with
legally separate medical staffs
§482.12: Medical Staff Member on
Governing Body
• Proposed: “A hospital’s governing body must
include at least one medical staff member.”
• This was defeated following input by the AHA
that stated that physicians:
May not be permitted by boards appointed by the
county/state under statute
May have conflicts of interest
Need for communication may be satisfied in other ways
§482.22(a): Non-Physicians on the
Medical Staff
• “The medical staff must include doctors of
medicine or osteopathy. In accordance with
State law, including scope-of-practice laws, the
medical staff may also include other categories
of non-physician practitioners determined as
eligible for appointment by the governing body.”
• CMS rejected the notion that non-physicians
could be privileged to practice without
membership on the medical staff
§482.22(b)(3): Medical Staff
Leadership
• “The responsibility for the care and conduct of
the medical staff must be assigned only to….
Doctor of medicine or osteopathy
Doctor of dental surgery or dental medicine
Doctor of podiatric medicine
…when permitted by State law”
• CMS rejected the proposal that PAs or APNs
serve on medical staff leadership
§482.23(c)(6): Self-Administered
Medications
• Hospital may allow the patient (or support
person) to self-administer hospital or non-
hospital medications as specified in hospital
policies
• Hospital must provide: written orders to
authorize, capability of patient (support
person) to self-administer, instructions on safe
administration, security of medications,
documentation of safe administration
§482.24(c)(3): Standing Orders Standing orders are now permitted as long as
the hospital provides:
• Medical, nursing, and pharmacy staff approval
process for written/electronic standing orders,
order sets, and protocols
• Orders based upon nationally recognized
evidence based recommendations
• Periodic review of all standing orders
• Orders that are appropriately dated, timed and
authenticated
§482.24(c): Verbal Orders
• Permits authentication of verbal orders by the
ordering practitioner or another practitioner
caring for the patient as long as they meet
hospital and State requirements
• 48 hour limit is removed
• Read back, appropriate date, time,
authentication still required
• What is the safest approach?
2013 CoP Changes:
• Practitioners who may order hospital
outpatient services (not on staff and permitted
by medical staff and State law)
• §482.12(a)(10): Governing body must
regularly consult with the individual
responsible for the organized medical staff or
his/her designee with regard to the quality of
care provided to patients
2013 CoP Changes:
• §482.54(a)(10): Practitioners may be
authorized to order outpatient services if they
are:
Responsible for the care of the patient
Licensed in the State where care is provided
Acting within his/her scope of practice per State
law
Authorized per board approved medical staff
policies and procedures
2013 CoP Changes:
• §485.631(b)(2) and §491.8(b)(2) :
Physicians shall provide oversight of patients
at critical access hospitals (CAHs), rural health
clinics (RHCs) and federally qualified health
centers (FQHCs) must be present for sufficient
periods of time to properly oversee patients
and services. (Eliminates the every 2 week
rule and permits greater flexibility)
2013 CoP Changes:
• §491.2: Definition of a physician for rural
health clinics (RHCs) and federally qualified
health clinics (FQHCs) shall include doctors
of: medicine, osteopathy, dental surgery,
dental medicine, optometry, podiatry,
chiropody (chiropractor)
Major Joint Commission 2014 Changes
for Hospitals:
1. Emergency Management and the
responsibility of leaders to put together a
comprehensive Emergency Operations Plan
(EOP)
2. National Patient Safety Goal #6 on improving
the safety of clinical alarm systems
Emergency Management:
• Response to increasing number of ‘disasters’
nationally (e.g. 2013 Boston Marathon)
• Emergency Operations Plan (EOP): mitigation,
preparedness, response, and recovery with
staged emergency response exercises
• Hazard Vulnerability Analysis (HVA)
• Coordination of disaster privileges (72 hours)
for LIPs through state/federal systems (e.g.
DMAT, MRC etc.)
Clinical Alarm Systems:
• Alarm failure and alarm fatigue cause
innumerable deaths in hospitals (ECRI
Institute: “#1 medical hazard of 2014”)
• Alarm system safety must be a hospital priority
as of July 1, 2014 and policies and procedures
must be in place as of January 1, 2016
Other deemed status accreditors:
• HFAP: OPPE/FPPE to be addressed by
January 1, 2015, discharge checklist required,
must verify medications from home by history
• DNV: New Standards to be released later
2014
• CIHQ: New Standards to be released later
2014
What lies ahead?
• Greater clinical and leadership responsibilities
will be granted to non-physicians due to
physician shortages and growing demand
• Greater flexibility in medical staff structures
with continued consolidation
• More patient centered approaches to care
• More focus on ambulatory services
• Greater focus on quality, safety, and cost-
effective models
