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The compliance tip of the month for February is focused on contract services specifically related to The requirement to evaluate the quality of the services provided at least annually as well as the requirement regarding metrics that are established to aid in the evaluation process.

The challenge for organizations seems to center around the incorporation of the evaluations into the QAPI program including the data gathered. This is typically cited in two Conditions of Participation, one at Governing Body and again at QAPI.

The CMS regulations are included below. Additionally, the CMS interpretive Guidelines are included for further clarification if available.

The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services.

The governing body has the responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice, irrespective of whether the services are provided directly by hospital employees or indirectly by contract. The governing body must take actions through the hospital’s QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. See §482.21 QAPI.

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 or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.

There are no interpretive guidelines for this standard

The following resources are provided to CIHQ accredited organization as well as ARS member to assist with compliance to this regulation:

#1800 – Form – Contract Service Evaluation Tool
#1096 – Form – Contract Service MOU on Expectations Defined in Writing
#1827 – Policy – Management of Contract Services
#1022 – Tool – Patient Care Contract Services Tracking Log
#1040 – Tool – Quality Metrics to Evaluate Contract Services

#19 – CMS Requirements for Contract Services

CIHQ is on track for redesignation by CMS as an approved accrediting organizations for hospitals. We were approved and published in the Federal Register on December 19, 2022. Below is a link for your reference. Federal Register :: Public Inspection: Medicare and Medicaid Programs: Application from the Center for Improvement in Healthcare Quality for Continued Approval of its Hospital Accreditation

The longest designation that CMS can award is for six years. CIHQ was awarded a five-year designation. This was determined based on budgetary issues at CMS. They were not able to shadow a survey which is a part of the application process which prohibited them from awarding the full six years.

CIHQ is expanding its accreditation programs to Critical Access Hospitals.

• Submission of the Application – Submitted on October 4, 2022.
• The application has been deemed complete by CMS and the review of the CIHQ standards crosswalk to CMS CoP for CAH has begun. We will keep you updated as we move through this process. We have completed the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
  • Northeastern Vermont Regional Hospital
  • Jackson County Hospital District
  • Glen Medical Center
  • Union County General Hospital
  • Pawnee Valley Community Hospital
• Next steps will be a virtual office review occurring on January 19 – 20, 2023, and shadow survey scheduled for February 2023.
• We will be published in the Federal Register on or by May 26, 2023

CIHQ is expanding its accreditation programs to Critical Access Hospitals.

• Submission of the Application – Submission is scheduled for February 2023
• The application, standards and process review will occur. We will complete the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
  • Griffin Memorial Medical Center
  • SD Human Services Center
  • Adventist Health Vallejo
  • East End Behavioral Health Hospital
  • Glendora Hospital – A College Behavioral Health Hospital
• Next steps will be a virtual office review, and shadow survey (dates to be determined)

CIHQ analyzes findings cited during accreditation surveys in order to track and trend the top findings. We do this primarily to evaluate whether or not ARS is supplying sufficient and effective resources to assist our facilities with compliance. This also guides the decision to add more tools and resources in order to facilitate compliance. This tracking is also used to evaluate the quality and consistency of how standards are applied and cited.