HOSPITAL FEDERAL REQUIREMENTS AND REGULATIONS. Presented by: Lourdes I. Cruz RN,MSN Puerto Rico Medicare State Training

Transcription

1 HOSPITAL FEDERAL REQUIREMENTS AND REGULATIONS Presented by: Lourdes I. Cruz RN,MSN Puerto Rico Medicare State Training

2 HOSPITALS & FEDERAL REQUIREMENTS Hospitals are required to be in compliance with Federal requirements set forth in the Medicare conditions of Participation (CoP s) in order to receive Medicare payment. To determine if a hospital is in compliance with the CoP a survey is performed.

3 HOSPITALS & FEDERAL REQUIREMENTS CONT Certification of hospital compliance with the CoP is accomplished through observations, interviews and documentation reviews. The survey process focuses on a hospital s performance of patient-focused and organizational functions and processes. The hospital survey is the means used to assess compliance with Federal health, safety and quality standards that will assure that the beneficiary receives safe, quality care and services.

4 REGULATORY AND POLICY REFERENCE The Medicare Conditions of Participation for hospital found at 42CFR Part 482. Survey authority and compliance regulations found at 42CFR Part 488 Subpart A. The CMS State operations Manual (SOM) provides CMS policy regarding survey and certification activities.

5 SURVEY PROTOCOL /GUIDING PRINCIPLES Special attention on actual and potential patient outcomes, as well as required processes. Care and services provided are assessed including appropriateness of the care and services within the context of regulations.

6 SURVEY PROTOCOL/GUIDING PRINCIPLES CONT Patient care settings are visited, including inpatient units, outpatient clinics, anesthetizing locations,emergency departments, imaging, rehabilitation, remote locations etc. Actual provision of services and care are observed in order to assess whether the care provided meets the needs of the individual patient.

7 CoP QUALITY AND PERFORMANCE IMPROVEMENT PROGRAM The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide data driven quality assessment and performance improvement program. The hospital s governing body must ensure that the program reflects the complexity of the hospital s organization and services; involves all hospital departments and services (including those services furnished under contract) and focuses on indicators related to improved health outcomes and prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.

8 CoP QUALITY AND PERFORMANCE IMPROVEMENT PROGRAM CONT The QAPI program must incorporate quality indicator data including patient care data, and other relevant data. The hospital must use the data collected to monitor its effectiveness and safety of services and quality of care.

9 CoP QUALITY AND PERFOEMANCE IMPROVEMENT PROGRAM CONT The hospital must use data collected to: Identify opportunities for improvement and changes that will lead to improvement.

10 CoP QUALITY AND PERFOEMANCE IMPROVEMENT PROGRAM CONT The hospital must set priorities for its performance improvement activities that: Focus on high-risk, high volume, or problem-prone areas; Consider incidence, prevalence and severity of problems in those areas; Affect health outcomes, patient safety and quality of care.

11 CoP QUALITY AND PERFOEMANCE IMPROVEMENT PROGRAM CONT The hospital must take actions aimed at performance improvement and after implementing those actions,the hospital must measure its success, and track performance to ensure that improvements are sustained. The QAPI program must measure, analyze and track adverse patients outcomes. As part of its QAPI program, the hospital must conduct performance improvement projects.

12 EXECUTIVE RESPONSIBILITIES The hospital governing body (or organized group of individuals who assumes full legal authority and responsibility for operations of the hospital),medical staff, and administrative officials are responsible and accountable for ensure: Quality improvement and patient safety including reduction of medical errors. Priorities for improve quality of care and patient safety. The determination of number of distinct improvement projects conducted annually. That adequate resources are allocated for measure, assess, improve and sustain the hospital s performance and reducing risks to patients.

13 HOSPITAL CMS PATIENT SAFETY INITIATIVE On year 2011 the survey and certification group begun a pilot testing quality initiative, with a surveyor worksheet designed to help surveyors to assess compliance with hospital Cop for QAPI. This quality indicator tracer must be assessed during the on-site survey in order to determine compliance with the QAPI Condition of Participation.

14 HOSPITAL CMS PATIENT SAFETY INITIATIVE CONT Items are to be assesses primarily by review of the hospital s QAPI program documentation and interviews with hospital staff. The interviews should be performed with the most appropriate staff person (s) for the items of interest (e.g., unit/department staff should be asked how they participate in the hospitalwide QAPI program).

15 HOSPITAL QAPI WORKSHEET Part 1 Hospital characteristics n Hospital name n Address n CMS certification number n Date of survey n Total number of surveyors who participated on the survey. n Approximated time spent performing the survey n Accredited Deemed status n Date of the most recent accreditation

16 HOSPITAL QAPI WORKSHEET CONT Part 2 Data collection and analysis-quality indicators tracers. 3 distinct quality indicators (not safety analysis ) are trace answering multipart questions. Will be focus on indicators with related QAPI activities or projects.

17 HOSPITAL QAPI WORKSHEET CONT Part 3 Applying quality indicator information activities and projects. Elements to be assessed n Evidence of improvement activities focuses on area that are high risk (severity), high volume (incidence or prevalence) or problem/prone. n Evaluation regarding whether the hospital s leadership sets expectations for patient safety. n distinct quality indicators (not safety analysis) are trace answering multipart questions. Will be focus on indicators with related QAPI activities or projects.

18 HOSPITAL QAPI WORKSHEET CONT Part 4 Patient safety-adverse events and medical errors. Elements to be assessed n Evaluation regarding whether the hospital s leadership sets expectations for patient safety. n Patient safety tracers n To evaluate if the hospital conducted any QAPI reviews of adverse patient events.

19 HOSPITAL QAPI WORKSHEET CONT Part 5 Broad QAPI requirements and leadership responsibilities. Elements to be assessed n Evidence that the hospital has a formal QAPI programincluding written policies and procedures, budgeted resources, and clearly identified responsible staff-approved by the governing body after input from the CEO and medical staff leadership.

20 ROLE OF REGULATORY AGENCY AND THE HOSPITAL SURVEY PROCESS Evaluation of the culture of safety. A systemic facility culture that encourages and supports open communication and reporting of errors and potential errors. Surveyors will interview patients and all levels of staff to determine if a culture of safety is present and supported by the Governing Body. Patient voice. Surveyors interview patients to determine if the facility staff listens to the individual patient about his/her care. During the survey process surveyor will analyze management behavior, safety systems, and patient/employee perception of safety. The surveyors will question both patients and employees about the facility s support of open communication, consistent reporting of events/errors/near misses without fear of retribution, and evaluate if there are clear expectations for staff practices

21 WHAT IS HOSPITAL COMPARE? Hospital compare is a consumed oriented website that has information about quality of care at over 4,000 medicarecertified hospitals across the country. You can use Hospital Compare to find hospitals and compare the quality of their care. The information on Hospital Compare: Helps you make decisions about where you get your health care. Encourages hospitals to improve the quality of care they provide.

22 THE INFORMATION ON HOSPITAL COMPARE Helps you make decisions about where you get your health care. Encourages hospitals to improve the quality of care they provide

23 HOSPITAL COMPARE Hospital Compare was created through the efforts of the Center for Medicare & Medicaid Services (CMS) in collaboration with organizations representing consumers, hospitals, doctors, employers, accrediting organizations, and other federal agencies.

24 MEDICARE.gov HOSPITAL COMPARE What information can you get about hospitals? General information: Name, address, telephone number, type of hospital, and other general information about the hospital. Patients experiences: How recently discharged patients responded to a national survey about their hospital experience. For example, how well did a hospital s doctors and nurses communicate with patients and manage their pain? Timely & effective care: How often and quickly each hospital gives recommended treatments for certain conditions like heart attack, heart failure, pneumonia, children s asthma, stroke, influenza, and blood clots, and follows best practices to prevent surgical complications.

25 INFORMATION ABOUT HOSPITALS Complications: n How likely patients will suffer from complications while in the hospital or after having certain inpatient surgical procedures. n How often patients in the hospital get certain serious conditions that could have been prevented if the hospital followed procedures based on best practices and scientific evidence. Readmissions & deaths: How each hospital s performance on the readmission and death (mortality) measures compares to the national rate. Use of medical imaging: How a hospital uses outpatient medical imaging tests (like CT scans and MRIs).

26 OTHER INFORMATION INCLUDED ON MEDICARE.gov Survey of patients' experiences (HCAHPS) The Centers for Medicare & Medicaid Services (CMS), along with the Agency for Healthcare Research and Quality (AHRQ), developed the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey, also known as Hospital CAHPS, to provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care. The HCAHPS Survey is administered to a random sample of patients continuously throughout the year. CMS cleans, adjusts and analyzes the data, then publicly reports the results. The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey is 32 questions in length 21 substantive items that encompass critical aspects of the hospital experience, 4 screening questions to skip patients to appropriate questions, and 7 demographic items that are used for adjusting the mix of patients across hospitals for analytical purposes.

27 HCAHPS SURVEY Composite topics Nurse communication. Doctor communication. Responsiveness of hospital staff. Pain management. Communication about medicines. Discharge information Care transition

28 HCAHPS SURVEY CONT Individual topics Cleanliness of hospital environment. Quietness of hospital environment. Global topics Hospital rating. Willingness to recommend hospital.

29 HCAHPS SURVEY CONT Hospital-level results are publicly reported on the Hospital Compare website 4 times a year. HCAHPS results are based on 4 quarters of data on a rolling basis.

30 WHICH PATIENTS ARE INCLUDED IN THE HCAHPS SURVEY? The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and 6 weeks after discharge; the survey isn't restricted to Medicare beneficiaries.

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