How to make sure your bases are covered
You probably are keenly aware of the need to comply with Joint Commission on Accredita-tion of Healthcare Organizations (JCAHO) requirements for performance improvement.
But are you in compliance with new performance improvement standards from the Centers for Medicare & Medicaid Services (CMS)?
The standards, which took effect March 25, 2003, require that you collect and compare data to assess performance improvements in key areas, including adverse patient events, the reduction of medical errors, and hospital operations.
CMS does separate random surveys to validate that there are not vast inconsistencies with JCAHO findings, explains Michelle H. Pelling, MBA, RN, president of the Newberg, OR-based health care consulting firm The ProPell Group.
"This supports continuation of deemed status," she points out.
Or, a facility could also undergo a full separate CMS survey because follow-up on a complaint indicated that there may be significant other issues that would require investigation and correction, Pelling adds.
If your facility does have a separate CMS survey, you will be evaluated using the CMS requirements, she says. "Most of them are the same as JCAHO, but there are a few variances."
For example, the requirement for "the hospital to measure, analyze, and track quality indicators including adverse patient events, processes of care, and hospital service and operations" is not significantly different from what JCAHO requires. CMS uses the word "improved health outcomes" whereas JCAHO uses the words "processes and performance" to a greater extent.
Both CMS and JCAHO require the prevention, identification and reduction of medical errors, Pelling explains.
"However, there are some differences in the language of the requirements," she says. "They are more prescriptive in some sections, and there are some slight differences." Here are the key differences in the requirements:
• CMS requires that the "frequency and detail of the data collection must be specified by the hospital’s governing body."
This is clearly greater involvement than most boards engage in, Pelling says. "Organizations should be careful not to pull the board into micromanaging their projects."
This requirement can be met by preparing the documents that specify the detail and frequency of data collection and putting them in front of the board for discussion and approval, with some explanation provided by the performance improvement coordinator, she says.
• CMS requires that "the number and scope of distinct improvement projects annually must be proportional to the scope and complexity of the hospital’s services and operations."
No numbers will be quoted, but this is not that different from JCAHO’s position, says Pelling, indicating that a 100-bed hospital with limited services would not be expected to engage in the same number or scope of projects conducted by a 500-bed tertiary hospital.
"The actual number and complexity is a judgment call to be made by hospital leaders and performance improvement professionals," she says.
• CMS requires the hospital to determine "the number of distinct improvement projects annually," which is much more specific than JCAHO.
However, this requirement is not without merit, Pelling argues. "It requires leaders to do better planning and think through how many projects are reasonable, in light of their resources," she says.
These include facilitators, clerical staff, and operational staff time to participate, considering other hospital initiatives, Pelling explains.
"Leaders should consider establishing a conservative number of projects," she says.
There always is the opportunity to add additional projects if leaders are presented with urgent or unexpected circumstances that require attention within the year, Pelling says.
CMS requires that "the hospital must document what quality improvement projects are being conducted, the reason for conducting these projects, and the measurable progress achieved on these projects."
Again, this is more specific than the JCAHO standards, Pelling says.
"However, it makes sense and holds the hospital leaders accountable — for both establishing projects based on sound rationale, and paying attention to how the projects are progressing," she says.
It is essentially a documentation requirement, and easily can be complied with using a chart such as the one below, Pelling adds.
[For more information on the CMS performance improvement standards, contact:
• Michelle H. Pelling, MBA, RN, President, The ProPell Group, P.O. Box 910, Newberg, OR 97132. Telephone: (503) 538-5030. E-mail: michelle@propell group.com. Web: www.propellgroup.com.]
You probably are keenly aware of the need to comply with Joint Commission on Accredita-tion of Healthcare Organizations (JCAHO) requirements for performance improvement.
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