1 / 181

CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2013 Part 2 of 2 What PPS Hospitals Need to Know

CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2013 Part 2 of 2 What PPS Hospitals Need to Know. Speaker. Sue Dill Calloway RN, Esq. CPHRM, CCMSCP AD, BA, BSN, MSN, JD President of Patient Safety and Education Consulting

claire-crawford
Télécharger la présentation

CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2013 Part 2 of 2 What PPS Hospitals Need to Know

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2013Part 2 of 2What PPS Hospitals Need to Know

  2. Speaker Sue Dill Calloway RN, Esq. CPHRM, CCMSCP AD, BA, BSN, MSN, JD President of Patient Safety and Education Consulting Board Member Emergency Medicine Patient Safety Foundation www.empsf.org 614 791-1468 sdill1@columbus.rr.com 2 2

  3. Visitation 215 10-7-11 • A hospital must have written P&P regarding the visitation rights of patient • Must include any reasonable or clinically necessary restrictions • Does not recommend restricting visitation in ICU • Same day surgery patients may wish to have a support person present during pre-op and post-op recovery • An outpatient may wish to have a support person present during examination by the physician

  4. Visitation 215 10-7-11 • Need written P&P to address patient’s right to have visitors • Any restrictions must be clinically necessary or reasonable • Can be restricted if interferes with the care of the patient or others • Restrictions for child visitors • Restrictions may include; infection control issue, court order, disruptive visitor, patient or room mate needs rest, inpatient substance abuse program, patient is having a procedure, etc.

  5. Visitation Rights Notice 216 • Hospital must have written P&P on visitation rights • Policy includes the restrictions • Hospital must inform each patient of any restrictions to visitation and must document it was given • Inform patient of the right to receive visitors their choose and they can change their mind • This includes spouse, same sex partner, friend, or family • Support person may be the same or different from the patient representative • Any refusal to honor must be documented in the chart

  6. Patient Visitation Rights 217 • The hospital policy must ensure that all visitors enjoy full and equal visitation rights no matter who they are • Can not discriminate based on sex, gender, sexual orientation, race, or disability • Surveyor will ask patients if visitors restricted against their wishes and if so was it in the P&P • Hospital needs to educate the staff • Consider in orientation and periodically • Should have a culturally competent training program

  7. Support Person

  8. Hospital CoPs for QI 2013 • CMS issued new hospital COPs for QAPI and now stands for Quality Improvement and Performance Improvement • Effective March 25, 2003 and amended 4-11-08 and 10-17-08 and no changes 6-5-09 • Starts with tag number 0263 • Short section because the hospital compare program is not part of the CMS CoP • Hospital compare is the indicators that must be sent to CMS to receive full reimbursement rates

  9. Hospital CoPs for QI • CMS issued new hospital COPs for QA and Performance Improvement • CMS issues Memo March 15, 2013 on AHRQ Common Formats • Hospitals are required to track adverse events for PI • Starts with tag number 0263 • Short section because the hospital compare program is not part of the CMS CoP • Hospital compare is the indicators that must be sent to CMS to receive full reimbursement rates

  10. Adverse Event Reporting • Hospitals are required to track AE • Several reports show that nurses and others were not reporting adverse events and not getting into the PI system • OIG recommends using the AHRQ common formats to help with the tracking • States could help hospitals improve the reporting process • Encouraged all surveyors to develop an understanding of this tool

  11. hwww.psoppc.org/web/patientsafety

  12. Hospital Common Formats

  13. Hospital CoPs for QI) • Must have PI program that is ongoing and shows measurable improvements, that identifies and reduces medical errors • Diagnostic errors, equipment failures, blood transfusion injuries, or medication errors • Medical errors may be difficult to detect in hospitals and are under reported • Make sure incident reports filled out for errors and near misses

  14. CMS Hospital CoPs • Triggers can help hospitals find errors • Trigger tools available on IHI website1 • Program must incorporate quality indicator data including patient data (274) • Look at information submitted to or from QIO 1www.ihi.org

  15. CMS Hospital CoPs • QIO to advance quality of care for Medicare patients • Sign up with your state QIO to get newsletters and other information • Use data to monitor safety of services and quality of care (275) • Identify opportunities for improvement (276) • Board determines frequency and detail of data collection (277) • Focus on high risk, high volume, or problem prone (285)

  16. QAPI • Must not only track medical errors and adverse events but also analyze their causes (287, 310) • RCA is one tool to measure causes • Hospital must take action based on data (289) and measure its success (290) • Example; process hospitals took to get MI patient timely thrombolytics and timely antibiotics and blood culture for pneumonia patients • TJC moving toward accountability measures and CMS toward value based purchasing

  17. QAPI • Hospital needs to document and track performance to make sure improvements are sustained (291) • Continue to track antibiotics given timely in the OR before surgical procedure and prophylactic treatment to prevent DVT/PE in major surgery patients • Number of PI projects depends on scope and complexity of hospital services so large hospital doing CABG would measure indicators on this • Hospital may want to develop and implement IT system to improve patient safety and the quality of care (299)

  18. QAPI • Hospital must document what PI projects are being done and the reason for doing them (301) and progress on it (302) • Board, MS, and administration are responsible for and accountable for ongoing program (309) • Decide which are priorities (312) and address issues to improve patient safety (313) • Clear expectations for patient safety are established (314) • Need adequate resources for PI and patient safety (315, 316)

  19. QAPI Patient Safety • This means people who can attend meetings, data so analysis can be made and other resources • Safer IV pumps, new anticoagulant program, implement central line bundle, sepsis, and VAP bundle, preventing inpatient suicides, wrong site surgery, retained FB, new processes for neuromuscular blocker agents, implement policy on Phenergan administration and Fentanyl patches • So what’s in your PI and Safety Plans?

  20. Medical Staff 0338 • Hospital must have an organized MS that operates under bylaws approved by Board • May only have one MS for entire hospital campus (all campuses, provider based-locations, satellites and remote locations) • Integrated into one governing body with the MS bylaws that apply equally to all • See previous MS sections 0044-94 • These have been discussed previously

  21. Medical Staff 0340 2013 • MS can include other categories of non-physicians determined to be eligible • But must follow state scope of practice law such as dietician, PharmD, NP, or PA • MS must periodically conduct appraisals of its members • MS bylaws determine frequency of appraisals • Recommends at least every 24 months (TJC C&P is 24 months) • To be sure they are suitable for continued membership

  22. Medical Staff 0340 • Must evaluate MS qualifications and competencies, within scope of practice or privileges requested • Look at special training, current work practice, patient outcomes, education, maintenance of CME, adherence to MS rules, certification, licensure and compliance with licensure requirements • Want to be sure the MS is credentialed and privileged to do what they are competent to perform

  23. Medical Staff Appraisals • Appraisal procedures must evaluate each member • To determine if should be continued, revised, terminated or changed • If requests for privileges goes beyond the specified list for that category of practitioners need appraisal by MS and approval by the board • Must keep separate credentials file for each MS member • If limit privileges must follow laws such as reporting to NPDB • MS bylaws need to identify process for periodic appraisals

  24. Medical Staff 0341 and 342 2013 • MS must examine credentials and make recommendations to the board on appointment of the candidates and must look at the following • Request for privileges, evidence of current licensure, training and professional education, documented experience, and supporting references of competence • Can’t make a recommendation based solely on presence or absence of board certification although can require board certification • MS must examine credentials of all eligible to be on the MS including non-physicians (NP, PA, PharmD etc.) • Telemedicine standards repeated in tag 342 & 343

  25. Medical Staff Organization 347 2013 • MS is accountable to Board for quality of medical care provided • If MS has executive committee, majority of members must be MD/DO • Responsibility for the MS is assigned to MD, DO, dentist or podiatrist • MS must be well organized-formalized organizational structure and lines are delineated between the MS and the Board & can have MEC Committee to represent MS • MS must have bylaws and must enforce bylaws and Board must approve bylaws

  26. Medical Staff • MS must adopt and enforce bylaws (353) • Board must approve bylaws and any changes also (354) • TJC has MS.01.01.01 which tells when to put things in the by-laws, rules or responsibilities or policies • TJC does C&P tracer since such an important area • MS bylaws must include statement of duties and privileges in each category, ( eg. participate in PI, evaluate practitioner on objective criteria, promote appropriate use of health care resources, 355)

  27. Medical Staff • Privileges for each category ( eg. active, courtesy, consulting, referring, emergency case) • Can not assume every practitioner can perform every task/activity/privilege that is specified for that category of practitioner • Individual ability to perform each must be individually assessed (core privileging, 355)

  28. Medical Staff • MS bylaws must describe organizational structure of the MS (356) • Lay out R&R which make it clear what are acceptable standards of patient care for diagnosis, medical, surgical care, and rehab • Survey procedure-describe formation of MS leadership • Survey procedure-verify bylaws describe who is responsible for review and evaluation of the clinical work of MS

  29. Medical Staff • MS bylaws must describe the qualifications to be met by a candidate for membership on the MS (eg. provide level of acceptable care, complete medical records timely, participate in QI, be licensed, Tag 357) • Survey procedure-MS bylaws describe qualifications as character, training, experience, current competence, and judgment

  30. H&P 358 • Repeated in tag number 461 and 463 • CMS changes standard to be consistent with TJC standard • MS must adopt bylaws to carry out their responsibilities on H&Ps • The bylaws must include a requirement that a H&P be completed no more than 30 days before or 24 hours after admission on each patient • Must be on chart before surgery

  31. H&P Admission • There needs to be an updated entry in the medical record to reflect any changes • Person who does the H&P must be licensed and qualified • Example, family physician does H&P 2 weeks ago for patient having CABG today • Surgeon would review, update, and determine if any changes since it was done and authenticate document

  32. History and Physicals • Can include in progress notes or has stamp sticker, check box, or entry on H&P form • Should say that H&P was reviewed, the patient examined, and that “no change” has occurred in the patient’s condition since the H&P was completed • There needs to be a complete H&P in the chart for every patient except in emergencies and can make entry in progress notes

  33. History and Physicals • New regulation expands the number of categories of people who can do a H&P • If state law and the hospital allows (which most do) a PA or NP may perform • Physician is still responsible for the contents and must sign off the H&P when done by one of these allied health professionals • Need to do PI to make sure all H&P are on the chart especially when the patient goes to surgery

  34. TJC PC.01.02.03 H&P • EP4 requires H&P no more than 30 days old and done within 24 hours • EP5 if done within 24 hours update, update prior to surgery (also RC.01.03.01) • EP7 that requires an update to a history and physical (H&P) at the time of the admission • RC.02.01.03 EP3 document H&P in MR for operative or high risk procedure and for moderate and deep sedation • MS.01.01.01 requires H&P process be in MS bylaws

  35. TJC MS.03.01.01 H&P • EP6 Specifies minimal content (can vary by setting, level of service, tx & services • EP7 MS must monitor the quality of the H&Ps • EP8 Medical staff requires person be privileged to do H&P and requires updates • EP9 As permitted by state law, allow individuals who are not LIPs to perform part or all of the H&P • EP10 MS defines when it must be validated and countersigned by LIP with privileges • MS defines scope of H&P for non inpatient services

  36. Autopsies 0364 • MS should attempt to secure autopsies in all cases of unusual deaths • Must define mechanism for documenting permission to perform an autopsy • Must be system for notifying MS and attending doctor when autopsy is performed • TJC has similar section

  37. Nursing Services 0385 • Must have an organized nursing service that provide 24 hour nursing services • Must have at least one RN furnishing or supervising 24 hours • SSA at 1861 (b) states you must have a RN on duty at all times (except small rural hospitals under a waiver) • Survey procedures-determine nursing services is integrated into hospital PI • Make sure there is adequate staffing • Survey procedure - look for job descriptions including director of nursing

  38. Director of Nursing Service • DON must be RN, A-386 (often referred to as chief nursing officer) • DON responsible for determining types and numbers of nursing personnel • DON responsible for operation of nursing service • Survey procedure-look at organizational chart • May read job description of DON to make sure it provides for this responsibility • May verify DON approves patient care P&P’s

  39. Nurse Staffing 392 • Nursing service must have adequate number of nurses and personnel to care for patients • Must have nursing supervisor • Every department or unit must have a RN present (not available if working on two units at same time) • Survey procedure-look at staffing schedules that correlate number and acuity of patients

  40. Nurse Staffing 392 • There are 3 recent evidenced based studies that show the importance of having adequate staffing which results in better outcomes • Study said patients who want to survive their new hospital visit should look for low nurse-patient ratio • Nurse Staffing and Quality of Patient Care, AHRQ, Evidence Report/Technology Report Number 151, March 2007, AHRQ Publication No. 07-E00511http://www.ahrq.gov/downloads/pub/ evidence/pdf/nursestaff/nursestaff.pdf

  41. Nursing Linked to Safety • IOM study also linked adequate staffing levels to patient outcomes • Limits to number of hours worked to prevent fatigue • Suggests no mandatory overtime for nurses • Never work a nurse over 12 hours or 60 hours in one week (or will have 3 times the error)

  42. Nursing Linked to Safety • Also showed medication error rate, falls, pressure ulcers, UTI, surgery site infections, gastric ulcers, codes, LOS, etc. linked to staffing • Redesigning the work force • See Keeping Patients Safe:Transforming the Work Environment of Nurses 20041 1www.nap.edu/openbook/0309090679/html/23/html

  43. Nursing Staffing Linked to Safety • AHRQ 2008 has published 3 volume, 51 chapter handbook for nurses at no cost • Great resource that every hospital should have • Nurse Staffing and Patient Care Quality and Safety • Again shows that patient safety and quality is affected by short staffing • Patient Safety and Quality: An Evidence-Based Handbook for Nurses, 20081 • 1http://www.ahrq.gov/qual/nurseshdbk

  44. Verify Licensure 394 • Must have procedure to ensure nursing personnel have valid and current license • Survey procedure-review licensure verification P&P • Can verify licensure on line by most state boards of nursing online • Considered primary source verification • Can print out information for employee file

  45. RN for Every Patient A-395 • A RN must supervise and evaluate the nursing care for every patient • RN must do admission assessment • Must use acceptable standard of care • Evaluation would include assessing each patient’s needs, health status and response to interventions

  46. Nursing Care Plan A-396 2013 • Hospital must ensure that nursing staff develop and keeps a current, nursing care plan for each patient • If nursing participates in interdisciplinary care plan then do not have to have separate nursing plan of care • Starts upon admission, includes discharge planning, physiological and psychosocial factors • Based on assessing the patient’s needs • Care plan is part of the patient’s medical records and must be initiated soon after admission, revised and implemented

  47. Agency Nurses 398 • Agency nurses or traveling nurses (CMS calls them non-employee nurses) must adhere to P&P’s • CNO must provide adequate supervision and evaluate (once a year) activities of agency nurses • Includes other personnel such as volunteers • Orientation must include to hospital and to specific unit, emergency procedures, nursing P&P, and safety P&P’s

  48. Preparation/Admin of Drugs 404 2013 • Drugs must be prepared and administered according to state and federal law (404) • Need an practitioner’s order • CMS changes to allow other practitioners who are allowed to order to sign off order such as PharmD as allowed by P&P and state scope of practice and MS bylaws/RR • Surveyor will observe nurse prepare and pass medications • Medications must be prepared and administered with acceptable national standards of practice (TJC MM chapter), manufacturer’s directions and hospital policy

  49. Changes to Tag 405 Medications 30 Minutes

More Related