STANDARD / ELEMENT EXPLANATION SCORING PROCEDURE SCORE

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1 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with The Medicare Hospital Conditions of Participation apply to both inpatient and outpatient services of the hospital. The hospital must be in compliance with all applicable standards within this manual in all on-campus and offcampus outpatient service locations. All outpatient services provided by the hospital, both on campus and at any provider-based clinics, must meet the needs of the patients, in accordance with The hospital must ensure that the services, equipment, staff and facilities are adequate to provide the outpatient services offered at each location in accordance with DOCUMENT REVIEW, OBSERVATION, CHART REVIEW, & FILE REVIEW 1. All on-campus and off-campus outpatient locations are compliant with all applicable conditions of participation. 2. Equipment, staff and facilities are adequate to provide the outpatient services offered at each location are in accordance with 3. The hospital s outpatient services are integrated into its hospital-wide QAPI program. Score compliance with this Condition of Participation based on the scoring throughout the requirements cited in this chapter. NA = Chapter Not Applicable in this facility. If the hospital offers outpatient surgical services, the surgical services Condition of Participation requires that the offered services must be consistent in quality with inpatient care in accordance with the services offered. The hospital s outpatient services must be integrated into its hospital-wide QAPI program. Acceptable standards of practice include standards that are set forth in Federal or State laws, regulations or guidelines, as well as standards and recommendations promoted by nationally recognized professional organizations (e.g., the American Medical Association, American College of Radiology, American Accreditation Requirements for Acute Care Hospitals 31-1

2 College of Surgeons, etc) Integration of Services. Outpatient services must be appropriately organized and integrated with inpatient services (a) The facility has a written plan for outpatient services. The hospital s outpatient services, at all locations, must be integrated with inpatient services (e.g., radiology, laboratory, surgical services, anesthesia (including pain management) services, other diagnostic services, etc.) as appropriate to the outpatient services offered. The hospital must have written policies in place to assure the integration of outpatient services, including an established method of communication between outpatient service departments to corresponding inpatient services. The hospital must coordinate the care, treatment and services to a patient. In order to provide continuity of care, it should have an established method of communication between inpatient services and outpatient care in order to provide continuity of care to its patients. DOCUMENT REVIEW, CHART REVIEW, & INTERVIEW Review the outpatient organization plan The outpatient organization plan is integrated with the inpatient services in accordance with the needs of the patient care provided at each of those locations. That the hospital has an established method of communication and established procedures to assure integration with inpatient services to provide continuity of care. Review medical records of outpatients who were later admitted to the hospital in order to determine that pertinent information from the outpatient record has been included in the inpatient record. Verify that the outpatient services are organized in a manner appropriate to the scope and complexity of services offered Personnel. 1. The hospital must assign one or more individuals to be responsible for outpatient services. 2. The hospital must have appropriate professional and nonprofessional personnel available at each location where outpatient services are offered, Outpatient services departments must be accountable to one or more individuals who direct the overall operation of the hospital s entire outpatient services (all locations, all outpatient services). The hospital must also define in writing the qualifications and competencies necessary to direct the outpatient services. Qualifications must include necessary education, experience and specialized DOCUMENT REVIEW & FILE REVIEW Review the organizations policies and procedures. Review the HR file and position description of that one or more individuals assigned to manage all outpatient services. All outpatient services are assigned to one (1) or more persons to manage the overall operation of Accreditation Requirements for Acute Care Hospitals 31-2

3 based on the scope and complexity of outpatient services (b)(1)-(2) training consistent with state law and acceptable standards of practice. Adequate types and numbers of qualified professional and nonprofessional personnel must be available to provide patients with the appropriate level of care and services offered by the hospital s outpatient department. The types and number of qualified personnel are based on the scope and complexity of outpatient services offered and the number and types of patients treated as outpatients. hospital outpatient services. The individual(s) responsible for all outpatient services meets the defined qualifications, in accordance with state law, acceptable standards of practice and hospital Review policies and contracts, if services are provided under an arrangement. Review the staffing plan and the weekly / monthly schedule. There is sufficient staff available by classification and volume to care for the patients served. The staff qualifications including education, experience, certifications, current licensure where appropriate and competencies are appropriate for assigned responsibilities. Review the position description and personnel file of the individual(s) responsible for the outpatient services to ensure that he/she meets the qualifications, in accordance with State law, acceptable standards of practice and hospital Review personnel files to verify that the staff qualifications including education, experience, certifications, current licensure where appropriate and competencies are appropriate for assigned responsibilities. Accreditation Requirements for Acute Care Hospitals 31-3

4 Compare duty rosters to patient log to verify that sufficient Doctor of Medicine / Doctor of Osteopathic Medicine, nurses and other staff are available to provide care to verify that the types and number of qualified personnel are appropriate for the types and numbers of patients receiving care, and the frequency, duration, and complexity of services offered. Review policies and contracts, if services provided are under an arrangement Documentation in Patient Records. All consultation reports, laboratory reports, radiology reports, etc., shall be reviewed with appropriate follow-up action noted in the outpatient record. Appropriate follow up shall be defined in the outpatient services policies and procedures. CHART REVIEW & DOCUMENT REVIEW Review policy and procedures. Review medical records for determination of appropriate follow-up action. 1. Follow-up expectations are defined in facility 2. Outpatient medical records demonstrate appropriate follow-up action, consistent with Patient Satisfaction Patient satisfaction questionnaires / comment cards shall be available for patients. DOCUMENT REVIEW 1. Patient satisfaction is measured for outpatient services. 2. Review data Activity Logs The facility shall have appointment / encounter / recall and phone logs in use that are up to date. DOCUMENT REVIEW Review the appointment / recall and phone logs. 1. Documentation is current and consistent with Accreditation Requirements for Acute Care Hospitals 31-4

5 After-Hours Resources. The facility shall have after-hours care arrangements in place with call schedules available for the patients. DOCUMENT, REVIEW, & INTERVIEW Review after-hours arrangements. If possible, interview a patient 1. Processes are in place to meet this requirement. 2. The after-hours care arrangements are clearly communicated to patients Referrals. The facility shall have arrangements in place for referring patients that require higher level of appropriate care (i.e. hospitalizations, consults, procedures, diagnostics). INTERVIEW Interview the person responsible for outpatient service. 1. Arrangements for these levels of care are in place For Future Use For Future Use Storage. The commodities supplied to patient care and support services are stored in such a manner so as to protect them from damage, or loss, such as from moisture, thermal change, rodents, vermin, or theft. OBSERVATION Observe supply carts, cabinets, and storeroom(s) Supplies are appropriately stored and protected from damage due to moisture, temperature changes, theft, and etc. Accreditation Requirements for Acute Care Hospitals 31-5