Joint Commission, CMS requirements may be inconsistent: Here are strategies
Organizations being cited for non-compliance
Is your organization's process for obtaining informed consent in compliance with both the Centers for Medicare & Medicaid (CMS)'s Conditions of Participation and the Joint Commission's accreditation standards? Would it surprise you to know that in this case, CMS' requirements are stricter?
CMS now requires that your organization's informed consent form include not only the name of the person performing a surgical procedure but also the names of people performing important parts of the procedure, even if these are done under the surgeon's supervision. If other surgeons, residents, or non-physicians assist with surgery, their name and what they are going to do must be included on the consent form.
Joint Commission surveyors already have cited a number of organizations for not complying with this requirement, says Michelle H. Pelling, MBA, RN, consultant with the ProPell Group, a Newberg, OR-based consulting firm specializing in regulatory compliance. Many organizations are not aware of stricter CMS requirements, and just keeping up with ongoing changes with Joint Commission standards and National Patient Safety Goals is often overwhelming, she adds.
"On top of that, the Joint Commission standards often require interpretation in order to understand all the nuances to be fully compliant," says Pelling. "The CMS requirements tend to be more time-consuming to read and interpret."
Hospitals getting RFIs
Most organizations lack adequate resources to do a detailed review and comparison of the two bodies of requirements, says Pelling. "Certainly many of the Joint Commission standards are similar to those of CMS, but there are some COPs that are not addressed in the Joint Commission's accreditation requirements," she says.
Joint Commission surveyors evaluate organizations for compliance with specific CMS requirements, such as informed consent or use of restraint, although some of the COP requirements are not explicitly reflected in Joint Commission standards, Pelling explains. If surveyors identify any degree of non-compliance with a CMS COP, they can give an organization a Requirement for Improvement (RFI), by applying standard LD.1.30, which states, "The hospital complies with applicable law and regulation."
However, how often this occurs varies, since individual surveyors may not be aware of all of the differences between the Joint Commission and CMS requirements or may choose not to survey for them, says Pelling. "In addition, they are often challenged by the time constraints of the survey and may focus first on assessing an organization's compliance with the Joint Commission standards," she says.
If Joint Commission surveyors learn, through a patient complaint or other process, about non-compliance with any governmental requirement, such as those from CMS, the Food & Drug Administration, the Occupational Safety & Health Administration, or a state licensure law, the hospital will be cited, says Margaret VanAmringe, MHS, vice president for public policy and government relations at the Joint Commission. "We always have the ability to take action for non-compliance with a statute that is not ours," she says.
However, VanAmringe notes that some 17 regulatory agencies have some say in hospital operations. "There are a tremendous number putting requirements on hospitals," she says. "It is important for hospitals to understand that there are more than just Joint Commission standards. There are so many and we don't know them all, which is why we can't survey them all."
Quality professionals tend to focus on Joint Commission requirements and may believe them to be the sole source of "standards" required, but this is not the case, says Nancy McLean, RN, BSN, consulting associate at Courtemanche & Associates, a Charlotte, NC-based firm specializing in regulatory compliance.
The Medicare statute states that as long as a hospital is accredited by the Joint Commission, it is deemed to meet the COPs. "So as long as our standards are met, it's expected that the government's are met," says VanAmringe. "But this has caused a lot of consternation in the field, because very often there is something very specific in a Medicare requirement which is not as specific in ours. We may allow for more latitude or creativity in meeting the standard."
However, the government takes the position that it doesn't matter if the requirements are exactly the same — it's the intent that matters. "The standards are taken as a whole. We don't have to have exactly word for word the same standards, as long as the goals are the same," says VanAmringe. "That's where people often are confused, because they see the specificity in the CMS standards and they don't understand why it's not in ours." For instance, the Joint Commission doesn't have a separate set of nursing-specific standards as CMS does, since these are integrated into the overall standards, but the overall intent is the same.
When Medicare updates its COPs, they are usually modeled after Joint Commission standards, notes VanAmringe. "There tends to be a closer affinity to our standards. Clearly when something is new, it will be very similar to ours," she says.
Differences are significant
Clearly, there are marked differences in the requirements of CMS and the Joint Commission. "We go through this problem every year when CMS validates our hospitals to make sure they are meeting the intent of the standards," says VanAmringe. "For example, at one point they applied the requirement for organ donation differently than we applied it. So little things like that that we have to adjust to." VanAmringe points to a chapter in the Joint Commission's Comprehensive Accreditation Manual for Hospitals called "Simplifying Compliance," which lists some of the major regulations that hospitals must comply with in order to meet their federal requirements. However, the list is by no means comprehensive, and the Joint Commission may consider supplementing it at some point, she says.
However, VanAmringe says the real problem is that Medicare has not taken the complete package of hospital requirements and updated them as a whole since the mid-1980s. "They have not had a comprehensive update since then, and the way we deliver care has changed," says VanAmringe. Services are now integrated and patient care is coordinated throughout the hospital, but the Medicare COPs aren't organized that way, she says.
"They are not systems focused, and they don't address patient safety throughout the organization as ours do," says VanAmringe. "We have pleaded with Capitol Hill to spur CMS into doing a wholesale revision. We think that would be in everybody's best interest."
The requirements are organized differently — the Joint Commission's by function and the COPs by department or service. For example, CMS has requirements for medical direction and qualifications for a medical director in many chapters, such as radiology and respiratory care, the surgical services condition has a requirement for an operating room register with ten data elements, and the laboratory condition includes a long section about the requirements for a "look back" program to track diseased blood that is found in the blood bank system.
"None of these requirements are explicitly specified in the Joint Commission accreditation manual for hospitals," says Pelling.
In other cases, both the Joint Commission and CMS may address a requirement, but the content for each is different. CMS requires a postoperative report with 10 content elements but doesn't require a time frame, whereas the Joint Commission requires a postoperative note that is immediate and has five content elements that overlap — but are not all part of the CMS list. Estimated blood loss is on the Joint Commission list, but not on the CMS list.
Another incongruity is the way that the Joint Commission and CMS assess life safety code compliance. "CMS usually gets the state fire marshal in there to spend days in the hospital and go over every little thing. If you have somebody solely focused on one area, they will always find something, whereas we are focused on many areas and have to prioritize," says VanAmringe. "Over the last few years, we have made some changes to approximate the survey that CMS would do, but that is still a challenge for us in being comparable."
Beginning in 2008, a life safety code specialist will be added to the survey team for one day for all hospital surveys. In addition, the time spent by the life safety code specialist during on-site surveys will increase to two days in hospitals with 750,000 or more square feet.
Now CMS has published a final rule, effective January 26, 2007, revising requirements in the hospital COPs for history and physical examinations, verbal orders, securing medications, and completion of post-anesthesia evaluations, and CMS's final rule on patient's rights imposes stricter standards for when a facility must report a death associated with the use of restraints or seclusion. (See related story on new CMS requirements.)
The Joint Commission has done a thorough evaluation of the new CMS standards and found no major differences, says VanAmringe. "We don't think there is a significant difference in those standards. There are just issues around the edges," she says. "We have spent much time with CMS trying to reconcile things. We work hard with CMS to try to minimize differences in the field."
However, CMS's new standards do include several requirements that are more prescriptive than the Joint Commission's. For example, the Joint Commission standard requires that verbal and telephone orders are authenticated within time frames specified by the organization, whereas CMS now requires that verbal or telephone orders are authenticated within 48 hours. "Unless a hospital's state requirements are more stringent, the hospital must comply with this new CMS rule," says Pelling.
Also, CMS now requires that a post-anesthesia note be documented in an inpatient's medical record within 48 hours of the procedure by an individual qualified to administer anesthesia, but the Joint Commission does not address the time frame required for a post-anesthesia note.
"The final rule will require some scrutiny of our current policies and procedures, so we can determine if any changes are necessary," says Pat Wardell, RN, vice president of quality management and patient safety officer at St. Jude Medical Center in Fullerton, CA. "As usual, the biggest issue for us will be making sure that state and federal laws are scrutinized and applied properly."
Unaware of 'CMS connection'
One of the biggest challenges for quality professionals is the ongoing need to continuously review all the publications, list servs, and information from professional organizations, and assess where there is need for revision. "It is imperative that someone is always alert to what is being changed," says Wardell. "With any change, an analysis is done to see if our processes are consistent with the change or need revision. Part of my job is to make sure I keep up with all the information that I receive and determine which items require action."
However, quality professionals generally are unaware of the influence that CMS has over their operations and over the Joint Commission itself, says McLean. "A good example of this is the Joint Commission's move to tracer methodology," she says. "CMS and state surveyors have been using tracer methodology as their format to survey nursing homes for years."
Quality compliance professionals already find it a daunting task to maintain staff and physician compliance with the Joint Commission's 262 standards and 1,304 elements of performance, says McLean. "The CMS connection is often not understood or given any consideration, especially in small or stand-alone facilities," she says. "This issue is better handled by the larger hospitals or hospital systems that have their own access to federal lawmakers. It is the smaller facilities that suffer from a lack of awareness of these issues — until a Joint Commission surveyor enters their facility and determines that the facility does not comply with a federal regulation."
Unfortunately, the Joint Commission is slow to incorporate new CMS standards into its own published standards, she says. "This results in a delay of hospital implementation of processes or systems to meet new CMS requirements," says McLean. "Joint Commission surveyors are found to be very aware of CMS regulations that are not printed in the Joint Commission manuals." Depending on the surveyor and on the surveyor's experience at the facility, they may provide a "consultive" comment advising the staff about the new requirement, or they may add an RFI, says McLean.
"Surveyor discretion in when to cite the hospital with an RFI remains contentious," she says. Nursing home professionals are acutely aware of CMS regulations due to their annual state surveys, which use CMS regulations as their guide, she notes. "As a rule, nursing homes follow CMS requirements and hospitals follow Joint Commission standards," says McLean. "Maintaining staff awareness and knowledge of both of these is a challenge for quality professionals in the average hospital environment."
Since the requirements differ in many cases, compliance with both CMS and the Joint Commission is an ongoing challenge, says Leisa Oglesby, assistant hospital administrator of quality at Louisiana State University Health Sciences Center in Shreveport. "However, the Joint Commission and CMS appear to be trying to eliminate these differences and to merge into standards that both organizations can accept," she says.
One problem is that the COPs are very difficult to read and understand, says Oglesby. "It would be great if CMS would publish a summary in more readable terms, and distribute it via their data warehouse, QNet," she says.
"As far as being compliant in various requirements, the strictest requirement is what we try to adhere to," says Sandra L. Abnett, BS, CPHQ, RHIT, director of quality management at York, PA-based Wellspan Health. "I really believe it would help if the Joint Commission would develop crosswalks between their standards and the CMS standards, as they are planning to do in home care."
Here is what organizations are doing to ensure compliance with the new CMS requirements:
• Share comparison summaries.
Organizations should work with their vendors and others to share comparison summaries, advises Oglesby. "We work with our vendor that risk adjusts and uploads our data to the Joint Commission and CMS," she reports.
• Do chart audits and mock surveys.
At Louisiana State University, compliance with the new CMS requirements will be confirmed through ongoing chart audits and during mock surveys. Using a crosswalk that compares both CMS and Joint Commission requirements to determine which has the stricter requirement is a good way to get started, says Pelling. "However, organizations who want to be confident that they are in compliance with CMS requirements should conduct a CMS-specific compliance assessment," she says. "We have done many onsite consultations with that primary objective."
Another good option is to purchase a COP compliance manual and conduct a self-assessment, using one of the tools available to hospitals. "I would encourage hospitals interested in performing their own assessment to not only review a crosswalk, but also select one of the tools that offers comprehensive worksheets that cover every requirement in every chapter," says Pelling.
• Network with departments within your organization.
As a large health care system, many different departments at Wellspan Health receive information on new regulations, including legal, compliance, quality, patient safety, and risk management. "These departments are informed on new regulations via e-mail, conference calls, and association meetings," says Abnett. "We network within our facility to share information on the regulations and ways to structure for compliance."
For instance, the organization's legal department first received the information on the patient grievances standard addressed by CMS recently, then spread the news to other departments. "We all listened to the conference call and then developed our strategies to be compliant," says Abnett.
[For more information, contact:
Sandra L. Abnett, BS, CPHQ, RHIT, Director of Quality Management, Wellspan Health, Corporate Office Center, 45 Monument Road, York, PA l7403. Telephone: (717) 851-5869. E-mail: [email protected].
Nancy McLean, RN, BSN, Courtemanche & Associates, PO Box 17127, Charlotte, NC 28227. Telephone: (704) 573-4535. Fax: (704) 573-4538. E-mail: [email protected].
Leisa Oglesby, Assistant Hospital Administrator of Quality, Louisiana State University Health Sciences Center, 1541 Kings Highway, Shreveport, LA 71130. Telephone: (318) 675-5030. Fax: (318) 675-4646. E-mail: [email protected].
Michelle H. Pelling MBA, RN, President, The ProPell Group, PO Box 910, Newberg, OR 97132. Telephone: (503) 538-5030. Fax: (503) 538-0115. E-mail: [email protected].
Web: www.propellgroup.com.
Pat Wardell, Vice President, Quality Management and Patient Safety Officer, St. Jude Medical Center, 101 E. Valencia Mesa Dr., Fullerton, CA 92835. Telephone: (714) 992-3000, ext. 3763. E-mail: [email protected].]
Is your organization's process for obtaining informed consent in compliance with both the Centers for Medicare & Medicaid (CMS)'s Conditions of Participation and the Joint Commission's accreditation standards? Would it surprise you to know that in this case, CMS' requirements are stricter?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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