About The Journal of Healthcare Management
The Journal of Healthcare Management is a publication of the American College of Healthcare Executives (ACHE) featuring articles on current healthcare management topics and industry trends. The journal is published six times per year and presents scholarly studies and columns by healthcare executives, industry experts and clinicians.

Practical Advice for 2010
“Guide to CMS Compliance” focuses on recent and anticipated changes in CMS regulations and offers insight into trends for the upcoming year, including more surveys and greater regulatory scrutiny. Elzer presents recommendations for understanding CMS regulatory requirements and presents practical approaches to delivering compliant patient care and responding to poor surveys.

About Ruth Elzer
Ruth Elzer is an expert at keeping hospitals compliant. As the Practice Leader for Accreditation and Compliance Services at Compass Clinical Consulting, Ruth gives clients practical solutions that work across the board. Before specializing in accreditation and compliance, Ruth worked for St. Joseph Medical Center in Joliet, IL, and at The Joint Commission (TJC), where she managed the development of educational programs designed to help hospitals prepare for regulatory survey. Ruth is trained as a surveyor for not only The Joint Commission, but also CMS and EMTALA. A nationally recognized speaker, Ruth is a member of the American Organization of Nurse Executives (AONE) and ACHE.

The article can be downloaded free from Compass Clinical Consulting’s Accreditation Resource Center.

Your quality team has studied the new standard changes, updated policies, and conducted tracers to monitor compliance. What else can you do as an executive to help your hospital prepare for more rigorous regulatory surveys? Communicate with your board!Currently, the Centers for Medicare and Medicaid Services (CMS) require hospitals to have a governing body (the board) that is legally responsible for the conduct of the hospital as an institution. The board of a hospital must hire the CEO, establish a competent medical staff, and oversee key aspects of the organization, such as the strategic plan and budget. However, it’s the governing body’s role in oversight of quality care that is most commonly cited during a complaint survey.

Rather than taking an active role in ensuring patient safety, most boards feel forced into a “rubber stamp” approach to quality oversight. This is often due to a combination of factors, including confusion about how the board oversees quality and lack of adequate knowledge about patient safety. But, hospital executives can support the board in fulfilling their responsibilities. Follow these guidelines to ensure that the board is an effective resource for your hospital.

Provide your board with an orientation. While not explicitly mentioned in the standard, board orientation has become an expectation for both CMS and The Joint Commission. Board members should receive an orientation to the hospital’s operations and quality program, as well as opportunities for additional education, if needed. Orientation also provides a chance for you and your hospital’s quality team to learn more about the needs and preferences of the board. What kinds of people serve on the board? What are their professional backgrounds? What kinds of report formats would best convey information to them in a meaningful way?

Make quality information universally understandable. Hospital boards generally consist of people from a wide variety of professional backgrounds. While many members may have some knowledge of basic quality control, it is likely that they do not know very much about the hospital’s quality standards. Therefore, the hospital must inform board members about quality care in a way that makes sense to them. Reports should be written for a lay (non-healthcare) audience and emphasize meaningful information over data.

Outline and document specific expectations for board members. In order for the board to effectively oversee patient safety (or operations in general), members must be engaged, interested, and willing to ask questions. Let your board know that you expect members to challenge old ideas, and encourage inquiry when appropriate.

Hold the board accountable for oversight. Boards receive quality reports for two reasons, to gain information and to direct action. Be clear when you want the board to take action on an identified issue, state your recommendation, then allow the board the opportunity to act. Merely approving a report is not meaningful action when there are problems. Once expectations have been stated, follow up in subsequent meetings.

Maintain transparency. Keeping the board informed is extremely important, particularly if your hospital is facing financial difficulties or adverse survey results like Immediate Jeopardy. A properly informed board can be the hospital’s greatest asset when it comes to communicating with the community and mitigating the impact of financial downturn or negative survey results. On the other hand, leaving the board in the dark about poor survey results can be disastrous, not only for reversing the findings, but in the loss of trust with the board and the community they represent. For more information and the story of one hospital that learned this lesson the hard way, read “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing.”

Across the country, hospitals are finding themselves on the receiving end of unannounced regulatory surveys. Failure to be prepared for such surveys can, in the worst cases, lead to Preliminary Denial of Accreditation by The Joint Commission (TJC) or findings of Immediate Jeopardy by the Centers for Medicare and Medicaid Services (CMS). But, hospital leaders can avoid adverse survey findings and ensure patient safety by paying attention to seemingly small issues before they become big problems.

So, how do small problems grow? We have found that small problems become big problems for two reasons. They either go unseen, or are perceived to be smaller or less consequential than they actually are.

Lack of visibility is probably the most common factor that allows small problems to grow. Often, unseen patient safety issues lurk behind seemingly positive data. Executives and board members should look critically at the quality reports that they receive, not just for the information that is included, but also for the information that’s missing. Are scores for select core measures consistently reported to be in the top percentiles while others aren’t mentioned? Are certain departments regularly highlighted for good performance but there is no discussion of problems? In other words, are you getting almost entirely good news?

When it comes to quality and patient safety, no bad news can be a red flag. Given the numerous patient interactions involved in day-to-day operations, every hospital should experience some level of failure. If, as a hospital executive, you don’t routinely hear about little problems, you’re probably missing the big issues, too. You can’t improve performance if you don’t know what needs to be improved.

So, when examining quality reports, look for the following signals that problems may be hidden or their gravity underestimated.

• Compliance with select core measures is consistently in the top percentiles.
  Core measures are important; there’s no denying that. But, they rarely tell the whole story when it comes to patient safety and regulatory compliance. Hospitals with nearly perfect core measure scores can still get into trouble on survey. Focusing on boosting core measure scores can divert attention away from day-to-day care. Also, CMS surveys are focused on compliance with minimum standards. So in many cases, core measures don’t correlate to compliance with CMS standards. For example, restraint and seclusion, a classic hot-button issue on CMS surveys, is not represented by a core measure.
• Certain departments are regularly highlighted for good performance.
  Every hospital will have stand-out departments that always do a good job of ensuring quality and patient safety. But, it’s important that you have a comprehensive view of all departments, not the just the best ones. Reports should cover every department at least once a year, with emphasis on patient outcomes. This type of strategy ensures that executives and board members and objective view not only of the entire hospital, but of the most important data.
• Reports focus solely on data and activities.
  While the current trend is to focus on risk reduction by improving processes, don’t forget that it’s important to understand how process improvements translate to better care. Be wary of reports that feature lists of actions and data without providing the analysis to show how those actions or data correlate to better patient outcomes. For example, reporting on the hours of sitter use is meaningless if those hours of supervision don’t lead to reduced use of restraints and fewer patient injuries. Also, appreciate that quality indicators are linked to other important business indicators. When more sitters are used, ask how this affects hitting productivity targets and how management responds to a productivity deviation.

Bringing minor problems to light before they have a chance to grow is perhaps the most important step toward preventing big problems. By keeping a critical eye and looking for warning signs, hospital leaders can ensure quality and patient safety by uncovering these small issues early.

To learn about one hospital where small problems turned into big problems, read “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing.”

Can a hospital have a near-death experience? If so, what would that look like?

For Haywood Regional Medical Center, “near-death” took the form of involuntary termination from Medicare. This traumatic event caused the hospital to lose physicians, morale, and its previously good reputation, not to mention significant amounts of money. But, with quick corrective action and strong leadership, the medical center regained its Medicare certification and received a second chance to thrive.

“Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing,” the new whitepaper from Compass Clinical Consulting, tells the story of Haywood Regional Medical Center, examining some of the factors that brought this hospital to the brink of collapse and the swift, strategic action that brought it back to life.

Recently, we have learned of a hospital that received an Immediate Jeopardy citation by CMS surveyors due to an employee potentially exposing patients to the H1N1 (swine flu) virus.   Other hospitals have reported dealing with an outbreak of the highly contagious Norwalk virus. 

While stressing the importance of infection control practices in the workplace, the CDC’s guidelines for preventing the spread of H1N1 flu virus recommend that sick employees stay away from work and that employers provide flexible leave policies.  

Many hospitals and their employees don’t follow these recommendations.

Besides the social pressures of not calling in sick, hourly employees, especially front line nurses, are penalized by loss of pay if they stay home when sick.   When employees work while sick, other employees and patients are exposed to increased risks, including prolonged hospitalizations and hospital-acquired infections. CMS now adds loss of accreditation or regulatory certification and legal liability to the list of reasons hospital leaders need to review their policies regarding sick employees.  

Transparency and mandatory reporting coupled with increased scrutiny of hospital-acquired infection can only worsen the cost of failing to protect patients from communicable diseases. 

We Recommend a Different Direction:

We think there is a solution for reducing the risks of employees working while sick. Encourage workers who think they may have an infectious disease to be screened by Employee Health (or they could go to their doctor).  If the employee has a communicable disease, they should be sent home with pay (and not use up a sick day).  This approach encourages workers to do the right thing while eliminating fake illnesses. Additionally, the information gathered through this process may also be useful for monitoring disease spread patterns.

While this has a short term cost impact, from a financial, regulatory and patient safety perspective it will produce a long term positive return on the investment.

Significant Changes – 87 New Requirements

The Joint Commission has 87 new and revised requirements for 2009. Although some standards contain minimal changes, others create new expectations and documentation requirements. Last-minute additions in January will require additional resources to address compliance.

Searching for Flaws

The new survey philosophy (”searching for flaws rather than searching for validation”) also makes it likely that there will be more adverse findings during survey.

Makes Compliance More Difficult

Because the standards leave much to interpretation, hospitals are vulnerable to misunderstanding during survey, making compliance more difficult.

Practical Solutions – Immediate Actions

The “Practical Advice for Surviving the Joint Commission and Survey Process” advanced educational seminar explains how to prepare for the survey process, focusing on the issues that hold the greatest risk for hospitals in 2009.  It provides practical solutions for taking immediate action towards the best possible survey outcomes.

How to Survive the Joint Commission and CMS

Upon completion of the seminar, participants will be able to:

1. Discuss the elements behind the tougher survey process for 2009.
2. Discuss the impact that the January CMS-driven standard additions to the Joint Commission manual will have on organizational readiness.
3. Identify three requirements that must be documented for the survey of the leadership standards by the Joint Commission.
4. Differentiate between the standards and survey processes of The Joint Commission and CMS.
5. Identify three areas of compliance that could lead to an RFI in their organization.

Related Links:

For more information review the complete description of  “Practical Advice for Surviving the Joint Commission and CMS Survey Process”

Registration form for the “Practical Advice for  Surviving the Joint Commission and CMS Survey Process” seminar.

The first step is to be proactive, limiting access to Social Security numbers, photocopied government IDs and other sensitive data.

The second step is for departments handling and coordinating patient data to secure that information and ensure financial and administrative managers do the same.

Finally, hospitals and partners should create systemwide best practices for managers to ensure all workers know the red flag policy triggers, proactively protect patient data, incorporate controls to only send payments to addresses listed on a user’s credit card and periodically update policies as new information about identity theft emerges.