And now, I would like to introduce our speaker to get us started this morning. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, Laura served as the Director of Facility, Patient Safety, and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experiences in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, Ms. Dixon provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. We thank you so much for being here with us this morning. Lauren, we invite you to go ahead and get us started with today's presentation. Okay. Thank you very much, Lindsay. And for those of you who are watching the PowerPoint, I do apologize. My cat decided she was going to help me move the slides along. So, she is now off my desk. So, again, I want to welcome everyone for today's program. We're talking about a very specific area called Governing Board and Contracts. Now, as we go through here, you may see here Governing Body, Governing Board. It's the same thing. And sometimes Joint Commission will call it the body, et cetera. So, just bear with us as we go back and forth. I've included in here the disclaimer that this program is informational only. It is not meant to serve as providing legal advice or establishing an attorney-client relationship. So, please reach out to your in-house counsel, your legal representative, as it relates to any particular advice, specifically those that address state law. So, why are we here today? Those of you who have had the, I should say, experience of having those surveys, which most of you probably have, you don't want to get one of these. That is the statement of corrections and statement of deficiencies where you have to do that plan of correction. And then there is also the one we never want to get. That's the involuntary termination from the Medicare and Medicaid agreement. This is when either you don't do a plan of correction or it's insufficient, didn't meet those really stiff deficiencies that CMS wanted. How does this all work? The regulation itself, the law starts in the Federal Register. And then CMS has a couple responsibilities. One, they have to publish the regulation into a transmittal, which tells their surveyors, hey, this is what's new. And then they have to bring together and develop interpretive guidelines and survey procedures so they can go out and do their job. Those of you who've listened to some of these programs over the past couple years, we're still waiting on some of those interpretive guidelines from the law that came out in 2020. We still don't have them. So if you happen to see they're pending, just bear with them. They're working on them. And then, of course, they have the responsibility to update the manual. And as it relates to your particular type of hospital, is it an acute hospital? Is it a critical access hospital? Surveys, there are three types. Certification, when you're getting started. Complaint, that's where, of course, there has been an issue, a patient or someone has filed a complaint with the state or CMS directly regarding what's going on at the hospital. And then the validation survey, and this can be where they're coming back or they're following joint commission or DNV. Those are two of the accrediting organizations. I'm going to touch on some of their requirements for the topic we're talking about. But lately, they've been tagging along just to make sure everything's according to what CMS would expect. How do we keep up with the changes? Subscribe to the Federal Register. That really keeps you up to date on what's changed, what is coming out new, because they will tell you before CMS will tell you. I'm sure you had the most recent manual. It did first come out in 86, and now, of course, multiple updates since then. And the last one for acute just came out in April of this year, April of 2024. I always recommend that if there is a new manual, go to the transmittal page, because that will take you right to what's changed. And then the survey and certification site, that's, again, where they send their memos out, their transmittals to say this is different. Slide number six has those email or, excuse me, the internet links. You will have to copy-paste. I've tried to make the links, but unfortunately, they don't work. So I just wanted to show you the appendix for the entire operations manual, because that lists out all of those facilities and services over which CMS has the responsibility. Hospitals are A, and critical access hospitals happen to be in appendix W. I want you to keep an eye on one other, and that is immediate jeopardy. Always have that in your back pocket so you can familiarize yourself with what they require. And so, again, here happens to be the table of contents for your manual in appendix A. You will see, again, it came out in April 2024. And to get to the transmittal page, when you go into the site, you will see that blue lettering. That's where you want to click, and appendix W has the exact same thing, but that's what it looks like. That's the transmittal page itself. And then you would hit the revision number, and just an example of what would pop up. It, again, takes you really quickly to what was revised, deleted, or what's new. And pay attention, of course, to revised and new, because that's where they really put the meat of it. The one that came out last month for acute hospitals addressed informed consent. It is only in the surgical area, and the surgical, tag 955 right now. I have a feeling they may expand that, but for now, it's only in that particular location, and it deals with getting consent for surgery when there might be a sensitive body part exam that could occur. So, for your memos, go to the link there, and that's what will pop up. You will see the posting date. That's where you want to pay attention for what is the most recent, and that's just an example of what one looks like. Again, this is directed to their surveyors to give them notice, hey, this memo's out, here's the new information. This is when it goes into effect. There is some that I'm still waiting for it to come out, and it has to do with the cultural issues with patients that hasn't come out yet, which I'm kind of surprised, because that rule goes into effect July of this year. Talk about deficiencies very quickly. We can access them. It's good if you're trying to do some benchmarking with yourself or one of your colleagues, or just find out where you are sitting and what CMS is looking at. It has the name and address for the hospital. It won't have the plan of correction, but you can get it, and what you'll do is you'll go to the link here where it says Hospital Surveys, and again, you'll click it, and you will see, I hate to tell you, a very large Excel document. Now, be aware there's two of them. One is for, I believe they start in 86 to 16. This one, you want to pay attention to is 2017 to current, so be aware that there are two of them on there. Just watch your dates, and of course, the most recent is the one you want to pay attention to, so for the items we're talking about today, you can see the board itself had multiple deficiencies for just as of December of last year, and some of them, yeah, there aren't too many of them, but taking into account, this is only from 2017 to 2023 for a total of roughly 1,400, so you may think, oh, that's not very many, but there's not very many years that we were looking at, and that included the pandemic years when they weren't doing so many surveys. Why were they cited? What was the basis of some of them? Well, a lot of it had to do with, you know, what was going on in the hospital. Not allowing a practitioner to do something they were privileged and credentialed to do, not following their own policies, not enough resources so they can port surgical services relating and resulting in delay of emergency surgeries, not making sure infection control quality insurance documents are even in place. They didn't make sure the medical staff was following its own bylaws, its own rules and regulations. Staff weren't trained to take care of patients who were violent or self-destructive. We didn't have certain things go through QAPI, such as medication errors. They didn't even hold the medical staff accountable for quality of care through that QAPI data. Not enough or didn't have supervisors for nursing. They didn't have an interim CEO. So that's just an example of some of the deficiencies that hospitals were cited over. So as we go through here, I always include the tag numbers on what we're focusing on, because some of this you may see, no, wait a minute, we started at 43 through 94, but then we changed. Now we're back down to 80. This is how I separated it out. I'm starting with the actual governing body. What are their duties and their responsibilities? Now, Lindsay mentioned we do have some questions. So I thought we'd just start right off the bat. Lindsay, you want to put that one up for me? I sure will. Let's get that one up here on the screen for you all. Okay, so you should now see this question on your screen that asks, our facilities board of directors, you can check all to apply to your organization here, only interacts with clinical leadership, communicates by emails, no visibility, provide regular reports regarding financial status of the hospital. They are readily visible and they do leadership rounds and interact with all levels of staff or possibly you have no information on the board. And again, you can check all that apply here to your organization. And for those of you who may have joined us just a few moments after we got started this morning, just note that during the time of these polling questions, and there'll be several more throughout the presentation this morning, we will also pause to address any questions that you have for Laura. So there at the bottom of your Zoom window, you should see that option that says Q&A. You can click on that and just type in your questions as you think of them. And then again, we'll make sure to address those questions during the time of these polling questions throughout the presentation. If for some reason you don't see the Q&A option, you can, of course, utilize the chat to type in your questions as well. Okay, we're getting some good responses here. I'll give it just another second or two. Okay. Go ahead and end that here and share those results. Okay. And I always want to just say right up front, I always appreciate when folks do participate because it gives me an idea about where you're located and what some of the issues, for example, that you might be. Might be a little bit different than what you're used to. So let's go ahead and talk about our governing board. You have to have an effective governing body. And what that means is this body, whether it's three people, 18 people, whatever it is, they are legally responsible for what goes on within your four walls. In other words, if there's a malpractice suit, they've probably been named in that lawsuit because they are responsible. So you have to have an effective governing body. And what that means is this body, whether it's three people, 18 people, whatever it is, they are legally responsible for what goes on within your four walls. If you don't have a designated board, what you do have to have is at least someone who's identified as a board member. in writing as responsible for the conduct of the hospital operations. Now, I want to just briefly mention, if you are in a hospital system, you can share a board with those hospitals, as long as each facility has its own CCN numbers. And, of course, if the state doesn't prohibit it. The nice thing is, is that, you know, you can share ideas across those systems if you do have that board. And sometimes it's a little bit more efficient. There is no survey, by the way, of hospital systems. They will, they're going to go into each and every hospital to visit. That's what they want to do. You can't have just one policy that goes across for that system. Now, each hospital can adopt the policy, but it must be clear that that hospital has elected to do so. A specific policy, where it's nursing, maybe it's lab, whatever it is. But there must be clear evidence that you have done so. In other words, it comes up in the board meetings, and they said, yes, we approved this policy for our hospital. And what actions do you take to make sure that it does apply to that hospital? So, overall, this, what you must have, is a functioning, effectively board, that holds the ultimate responsibility for compliance. In other words, anything that we talk about in CMS, anything like that, compliance, they're responsible for it. These are specific standards, and each and every condition of participation. And it doesn't matter if it happens to be a regulatory text that talks about, oh, a condition, that's with, or a standard within a condition, that mentions the governing body. It doesn't have to specifically say it. They're still responsible. Substantial noncompliance, which is at the condition level, with one of the conditions, may be an indicator that they're a governing body. And they will also, they being CMS, will look and consider the manner and degree of other deficiencies when they're doing these citations. By the way, if you're looking for this, it's on the new manual. It's on page 41 of that manual. So, real quick, again, on systems and nursing, they bring this up because, again, the board elects to have a system and policies. Now, for some reason, they don't allow a hospital, hospitals in a system, to have an integrated nursing service department. Don't ask me why, but they said no. You have to have, each hospital has to have its own nursing service department. Now, you can have a CNO to run it, to run both of them, if they're able to do it, but you can't have an integrated nursing service. You can have a system-wide or integrated QAPI. as long as each hospital accepts it. They had their own program and the board is for the QAPI sections. So they still allow it. Well, moving on. The next two topics I wanna talk about, it's kind of an overlap and that's board and medical staff. First off, the board has to make sure medical staff requirements are met and they have to determine who gets to play in their house, who a category of practitioners are going to be eligible for appointment to the medical staff. Could be physicians, could be chiropractors, podiatrists, dentists, optometrists, whoever they deem say, yeah, that's gonna be a benefit. You know, some of these large systems do because they have so many services that they offer. The medical staff, that includes a physician. They have a definition of a physician in the actual manual. Of course, that's someone who's legally authorized to practice in the state and within their scope of practice. CMS won't tell you what a physician assistant, what a physician, a nurse practitioner or any of those other practitioners can do. That's up to the state, the state medical board, podiatry board, nursing, whatever it happens to be. They determine the scope of practice. It's just the medical staff says, yeah, we're gonna give them credentials to do so as long as it's okay with the state. Otherwise the board gets to determine who else can come on to the medical staff as long as, again, it's consistent with state law. The general rule, and this is within the interpretive guidelines. If you're going to grant someone privileges, yeah, they should be appointed to the medical staff. There are blue boxes. That's what they call them, blue boxes in the manual. And they talk about credentialing even some, but not adding to the medical staff if it's prohibited by state law. And I'm just gonna bring up registered dieticians because for the longest time, registered dieticians were not allowed to, first off, be credentialed to write orders, but weren't even appointed to the medical staff, couldn't do that. And many of the states are starting to change that. So if you're looking for one of those different type of providers, you might wanna make sure the state law does allow them to be added to the medical staff. That's just example what that blue box happens to be. These are nice because it's really good information. There may be some resources in there for you, and you can't be cited if you don't follow or do what's in that blue box. Again, others can be eligible for privileges. That could be PT or OT, but the board does have to exercise oversight. We have to make sure that is done with the medical staff. In other words, the board makes sure the medical staff is doing what they're supposed to be doing for PAs. They have to make sure that they're credentialed, that the medical staff credentials these individuals, they're doing competency reviews, and it doesn't matter if they're actually appointed to the medical staff or not. And of course, we know the different levels of privileges, active courtesy, consultative, where it is, as long as it's allowed by state law, the bylaws, the rules, and regulations. The board appoints those individuals to the staff, and that's based on the advice and recommendations of the existing members of the medical staff. So you've got a physician coming on board, then the medical staff has the responsibility to do the credentialing, do that background check, see how they are, and then establish what privileges would they recommend that the board grant them. Then the board decides to grant those privileges or deny them. If you've got a current member, of course, the board can determine to revoke those privileges, but that has to be based on the recommendations of the medical staff, and of course, consistent with state law and the criteria that the medical staff spells out. So if you've got a physician where the medical staff says, you know, this provider isn't living up to the expectations for the criteria for that particular role that they're playing, then they make that recommendation to the board to say, I think we need to pull back on their privileges. It's time. The surveyor is going to want to see your board minutes. They want to make sure that the board is involved with the appointment of the medical staff members. The board has to make sure the medical staff has bylaws that they're playing according to what their rules are, and that they're complying with them, but they're also complying with state and federal laws, and here are the conditions. The board decides whether or not to approve what the medical staff has put together in their rules and regulations, their bylaws, and any changes, and any revisions, bylaws, any revisions to those, they have to be approved by the board before they're considered effective. The joint commission, and I want to point this out, especially for those of you who might have joint commission accreditation also, look to medical staff section. They have good information on what needs to go into a bylaw or rules or regulation. CMS won't tell you that, so that's why if you're looking for some guidance on it, I would look to what joint commission has in their medical staff regulation. The medical staff is accountable to the board for the care that they provide, or that is provided within the hospital, and they may need to make sure that as a group, the entire medical staff is responsible for that. Can't just be one person. the entire staff has to be. And again, because the board's responsible for what happens in that hospital, the conduct and the quality of care. All patients, this is this kind of brought up some discussion recently, all patients have to be under the care of a practitioner who has privileges or by a practitioner under the supervision of somebody who is a medical staff member. And of course, that protect practitioner who's operating within the privileges that the board has given to them. In other words, yes, I can order class to controlled substances, I can order x rays laboratory, I can perform surgeries, you have to still document an order. Even if you may have a protocol that follows it, there still has to be an order for care provided to that patient. On selection of the medical staff, there are five areas, five areas of criteria that must be reviewed in order for a medical staff member to be considered for selection, character, competence, training, experience, and judgment. Now many, many, many years ago, it was thought, oh, if you are board certified, that's sufficient, you're good enough. Or if you have a fellowship, that's great, come on board. Well, I found out that wasn't always the case. So that's why CMF beefed up their requirements for what they want to have the board confirm is being reviewed for their medical staff members. The bylaws, rules, regs, they describe what is that privileging process? How is that going to occur? And again, the board has to make sure that the bylaws to be added to the medical staff getting privileges, they're applied across the board, done to each category. So if I happen to be a neurosurgeon, that same information, the same process, and those same requirements for criteria are applied to me, as they would for say, a general practitioner, or maybe a nurse practitioner who we're going to allow on board. The surveyor is going to make sure you do have that written criteria for granting those privileges, and that it is based on that individual doctor meeting the criteria. And again, they will verify the criteria spelled out those five character, competence, experience, judgment, and training. That's what they're looking for. Again, they just want to make sure that under no circumstances is it based solely on board certification, fellowship, or a member of a specialty society. Some of you probably run into some providers who they're just the smartest kid on the block. And they've got board certification, several of them, they've been in fellowships, but they're not a good practitioner. And that's why CMS want to expand. Hey, this is what we need to look at to make sure these folks are safe. They included in board duties telemedicine, because they have to make sure that if you are going to do and provide either provide or obtain telemedicine services, that first off, it's a written agreement. And you can do it through a hospital or an entity. So that's one big thing is a written agreement. And the way this works is that your medical staff will go to the board and say we know of this hospital and they have really good telemedicine, especially for areas we don't have. And we need them because these folks are coming in through emergency room, for example. And so we want to use this distant site hospital or entity. And we want to be able to say first off, that this entity or hospital, they're complying with the conditions of participation. And what they do make sure we comply with the conditions of participation. The doctors who are going to be working with our patients and work with us, they're licensed in the state where our patients are located. And they can provide evidence that they have privileged and credentialed all of those who will be doing telemedicine for us. And we can get a copy of their privileges. So that's some of the things the medical staff has to make that recommendation to the board, because you can rely on the privilege and credentialing of that other hospital or entity, you can do that. You however, do have to send information back to that other hospital or entity. If you've got some problems with that service, like complaints, bad adverse events, keep a file one file for those telemedicine physicians, all together. So it's easy to find, because they somewhat act as an individual group in this service that's provided. The surveyors want a copy of that they want to see a copy of that agreement because they're going to go through for all of those items, they're going to make sure privileges were granted, that you relied upon those privilege and credentialing of that other site that yes, indeed, that you communicated back. If there was an issue with the care provided, how did you do that doesn't have to be a whole long dissertation. It's just that our chief medical officer will be in communication with the director of the telemedicine services on this these issues. And that there is a recommendation for each of the practitioners that are providing telemedicine survey to you. I'm going to touch on telemedicine a little bit later. But I wanted to give you that brief overview, because that was in that particular tag number. Otherwise, there has to be some communication between your medical staff and the board. And the board must not should but must consult directly with somebody who has that responsibility over the medical staff, whether that's the president, the CMO, whoever they designate at least one individual, there has to be that conversation, and do it throughout the year. CMS does recommend at least twice a year for your larger systems, your larger hospitals, teaching hospitals, you may do it every month, depending on what's going on, where the small event twice a year could be okay. can be on a fiscal year, can be on a calendar year, however it works for you. But really, it really has to cover what matters are talking about quality of care that's provided. Are there issues cropping up in one say one service? Maybe there's a problem with surgery. Or maybe there's a problem with behavioral health, that getting providers on board. Now, if you are in a multi hospital system, the board must consult directly with each CMO, or responsible person for that particular hospital for each and every hospital. And that's why you want to make sure that the person who's been given that designation or that responsibility knows that's what they have to do. As far as direct consultation, it must be synchronous. It can be face to face or by zoom meetings, whatever it is. But it must be synchronous, it can't be emails, that that's not going to be sufficient with CMS. And another thing with this consultation, that person who's on the medical staff, they can serve on the board, and and take care of that. Now, just because just because you have a doctor, let's say a medical staff person who is on the board, just if that's all they do, that doesn't meet the standard of periodic consultation, unless they are responsible, and they are designated as the leader. So that's where the documentation, your minutes, whatever it happens to be, has to be very clear that that is the capacity for which they are serving. And just make sure there's a discussion on care quality, and issues that must be on the agenda, so that that individual can meet all of those responsibilities. And if you're in a system with a single board, you have to meet with each hospital with their designated leader. They don't need to be separate, you can all meet together if you want, but there has to be at least that consultation. And if they have opted for a unified medical staff, then the board has to meet with the leader of that medical unified staff. So that person who you've got two hospitals, you're sharing medical staff between those hospitals, the leader has to be aware that they are responsible for bringing up issues and discussing each issue at those hospitals at each hospital. How many? Well, the board determines the number of consultations based upon how big are you? And what services are you offering? Are you really seeing an issue with safety or what's going on in the QAPI program? And there must be evidence that the board has responded. And especially if there's an urgent issue from the leader of that, you know, that medical staff, say, for example, you have a service where they are not getting along, and all of the members have decided to up and leave. That's an issue that needs to be addressed urgently. And so there has to be some evidence that, hey, this was done, and this is how we did it. Minutes are a good way to do it. Then the board has to adopt policy and procedures on how you put together this periodic consultation with the leader, how's it going to happen? And that you have evidence that they actually occurred, agendas, who was at the meeting, minutes of discussions. What did you talk about? Was quality of care included? Really, I'd make that just part of your monthly board book, period, then you're done. So that those issues, if they're there, can come up, maybe they're in progress. We're making strides. We've made these advancements. So that CMS is clear, yeah, the board is involved with that. The surveyor is going to talk to the CEO. This is the CEO. Did the hospital track those consultations? What evidence that they were direct by Zoom? Was it eye to eye? How was it? They want evidence the board meetings occurred with the CMO, or that designated individual at least again, twice a year. They'll talk to your physician leader. Did they have meetings with the board? When did they occur? How did they occur? What issues did you talk about? Did you have any other meetings that were scheduled besides the regular ones? And how did you get the meeting set up? What'd you talk about? So let's talk about the CEO for a minute, the chief executive officer. This person, most would say, I run the hospital, they manage the hospital. That's exactly what they're supposed to be doing. And the surveyor will make sure there is one CEO that's responsible to manage the entire hospital, and that the has been appointed by the board. In joint commission and their leadership standards, like they give you information for the board and the board minutes, they have a lot of good information on what is the CEO's role with that hospital? What are they expected to do? Board duties as it relates to care patients? Well, they have to make sure every patient's under the care of a physician. That can be a dentist, podiatrist, however it works within your definition. They have to make sure they're licensed, and that they are granted privileges to be a member of the board. For practitioners, PAs, nurse practitioners, etc. They can admit, but they still have to have evidence they're under the care of a physician. And if the state law allows, you have to make sure your policies and bylaws make sure you're complying with that. Can a PA admit according to state law? You don't have to allow that. You don't. But if the state says you can, then you're okay. Now the exception, there's a federal law that no supervision is required when you have a certified nurse midwife for Medicaid patients. Now I want to bring this up, because it is different. If you have a critical access hospital, we'll cover that in the critical access. But for acute hospitals, in other words, non-critical, if you have a midwife who wants to admit a patient, a Medicaid patient, and that's usually for birth issues, they don't have to be supervised by a physician under CMS. Which brings me to my question number two on admitting patients. Lindsay? Absolutely. Okay, let's get that one up here on your screen. Okay, so you should now see this one. And you can again, select all here that apply to your organization. My facility allows the following to admit patients, MD or DOs, only NPs, PAs, chiropractors, podiatrists, psychologists, dentists, or possibly you may not be sure here. And then while you're doing that, we do have one question that came into the chat, Laura, that asks, if providers are required to maintain BLS, ACLS, and PALS, or does their board certification cover them? That's up to their board certification. What does the medical staff want them to have? CMS won't tell them. And some states, they don't, you know, there's a lot that some states don't require that they leave that to the hospital to make that determination. Same with continuing ed. My state doesn't require nurses to have continuing ed. Most hospitals do now. They just say that's too important. So they require it. Perfect. Okay, I'm gonna go ahead and share those results here. Okay. All right. So good. Some of you are there's good variety of providers that are being allowed to admit. So let's start with Medicare patients only. And that's, they call them mid-levels. Yes, they are advanced practice providers. Medicare patients must be under the care of a physician. So in other words, there has to be evidence of such in the medical record. And again, the exception is the midwife patients that was done in a 2023 memo. I have that in the appendix for you. And the slide will show you what that memo looks like and the link, you can type that in and get it. Otherwise, they have to make sure there's a physician always on duty. In other words, in the building, or on call. Because again, they are responsible to monitor care of Medicaid and Medicare patients. Something the surveyor is going to do is ask the nurses, who's on call? How do you reach them? Do they come to the hospital? When you've called them? Do they, you know, get in contact with you? And I remember just doing bedside nursing, they did ask us that, you know, they'd pull us aside who's on call for cardiac today? How did you reach them? Are they available when you need them? Do they come when you ask them? So yes, they actually do do this. You also have to make sure that that physician is responsible for those who those Medicare patients for medical and psychiatric problems that are there on admission or develop during hospitalization. But outside the scope of practice for not just your providers, but others, like dentists, optometrists, clinical psychologists, you know, if you have these folks who are admitting patients, and say they have maybe CHF, or they're having an MI, that's a little bit outside the scope of what a dentist really can handle. And so that's why they want to make sure that a physician is going to take over and take care of that patient doesn't have to be medical. Again, it can also be behavioral health issues. Moving from patient care over to broader scope. The board has to make sure there's an overall institutional plan. This is a big thing. This is one that includes your annual budget, income and expenses anticipated income and expenses. They have this plan has to provide for your capital expenditures for a three year period of time. And how are you going to finance it? That could be land acquisition, maybe you're going to build a new building or improve a building get new equipment. Now if you're going to build a new surgical department or new wing for mom and baby, that's what has to be within that institutional plan. They actually have to submit this for review. The planning agency or health planning agency for your state. Now Joint Commission has similar standards in their leadership chapter. But they want to make sure that the board is heavily involved in keeping this hospital operational. Now there are certain exceptions to review where you don't have to get review by your planning if, excuse me, 75% of patients that use that service are in an HMO or another competitive medical plan. And the expenditure is for a building or services to operate efficiently and economically that aren't otherwise accessible. In other words, you don't have them on site. You can't get them through a contract. It costs more than if you do it direct. And you just don't have medical staff privileges available for that one. So again, there's certain circumstances where you don't have to get review of your capital expenditure. Otherwise, look at your plan, do it annually, update it annually. It has to be done under the direction of your board, and a committee of representatives. That means medical staff, administrative staff and the board. Administrative is your C-suite. And the surveyor will verify all three of these entities, these groups participated in that plan and budget. Because you know what medical staff may need may be a lot different than say what the administrative staff can see as viewed as necessary. Briefly on contracted services, I'm going to go into this again a little bit more in depth, but the board again is responsible for everything that happens, whether it's by your employees, or you do it through a contractor. And so if you do have a contractor that is providing services, they have to do so in a way that you as the hospital comply with all the conditions, and any standards that go along with those conditions. So how do they make sure? Well, first off, they want to make sure they're acting through the QAPI program, because they assess not only contracted services there, but those by your employees, they are responsible to make sure that any quality issues have been identified, and that they're being acted on, they're corrected, and that they are monitoring that corrective action. Is it sustainable? Do we need to go back and start over again? They have to make sure services are performed safely, that those under a contract, and so the surveyor will look at the QAPI plan, they want to make sure every contracted service is evaluated. So keep a list of all of those contracted services, and keep them, preferably in one spot, so that one isn't missed, that one isn't added inadvertently, that the board isn't aware of, or it's not being monitored. Briefly on emergency services. If you're going to, you know, if you do this, you have a dedicated emergency department. Just remember, EMTALA is a separate condition. It's a separate section for you. So if you are providing them, you must meet with these tag numbers. If not, if you have no dedicated emergency department, the board has to make sure that there are policies and procedures your medical staff put together to handle these. Because sure enough, one of them is going to walk in through your door somewhere or it's going to happen on site. In other words, they have to make sure that the policies address how do you appraise or appraise those emergencies? What kind of initial treatment can and will you provide? And of course, referrals. Where do you send these people? Do you have an agreement with the hospital? Not necessary, another hospital, but how are you going to do that? And this is for everybody, 24-7. Doesn't matter if it's on campus or some of your off-campus locations. Maybe you have a PT system that you provide or service that you provide. It's not within your hospital, it's off-site, but it's a part of your hospital. And you don't have a dedicated emergency room. And for those of you who've gone through PT, know sometimes it's a little uncomfortable and you've probably seen people who didn't react well to it. How are you going to handle that medical emergency? There has to be policies and procedures from the medical staff. On the appraisals, qualified are in, must be immediately available to assess the patient. And that's the person. They're going to run down and see what's going on. Physician has to be on site or at least on call because they may need to give some direction. On the initial treatment, again, the policy and procedures have to address it. What are you going to do? Is it oxygen? What are you going to do? And then, of course, referral. That's when what the patient needs is beyond your capability. 911 for transport, arranging other transport. Maybe they're stable enough and that they can go by an ambulance without sirens. Maybe they do need sirens. Now, I just put this in as a caveat. The practice of using 911 for those responses is required to maintain, in other words, what you are required to maintain to handle an emergency. And you just blanket use 911, that's not consistent with the conditions of participation. So let's say you use it to respond to a code in your ICU. No. Or respond to an anaphylaxis. No, that's not that's something the hospital must be prepared to address internally, not using 911. On the other hand, if you do have off campus emergencies, and they are still provided at your hospital, well, that's fine. You just have to make sure there's policies for what the staff can do at that offsite emergency. They have to be appraised by a qualified person. That may be, you know, doing a blood pressure, getting oxygen. And then you can use 911. Again, as long as it's not a substitute for what you are required to maintain. And there's limited capabilities at that off campus site. So you can use it if it's an off campus emergency. So that's acute hospitals. Now I'm going to move over to critical access hospitals. This one isn't in a separate section, like it is in their manual. It's not a separate section, like it is in the acute. You're under organizational structure. It's a very short, very short section. There's only four tag numbers total. And a lot of information that I've already covered will apply here also. There are very few deficiencies in this area. It was only 119. For some of the others, we had 700 plus. So here, critical, you can have a body or person who is responsible for everything that occurs in the hospital. They assume full legal responsibility. They have to make, determine, implement, and monitor policies on the total operation. They have to make sure policies are administered in order for you to provide safe, quality care. And really, the interpretive guidelines follow everything I've already talked about. You must have one governing body, someone who is responsible. If it is just a person, there must be written documentation that identifies that person is responsible. Some criticals go through this individual pretty quickly. They may change them every year, sometimes every six months, for a governing body, someone who's responsible. They, like the other hospitals, they determine the categories of practitioners. They appoint those folks to the medical staff based upon the advice and recommendations of the medical staff. And they decide, are we going to stay with this individual's current level? Are we going to appoint a new physician or provider? And they, again, use that established criteria, keeping in mind all state, federal laws and regulations. What this person or body has to do with the medical staff is, of course, make sure there's bylaws. And they decide whether or not to approve any of the bylaws or any revisions, because they have to make sure the medical staff is accountable for the quality of care. Again, responsibility for the conduct, and that includes quality. All critical access hospital patients must be under the care of a member of the medical staff. Now, I want to point this out. A member of the medical staff is different than a physician. That can be a practitioner who's under the supervision of a medical staff member. Now, most of you, they're going to have physicians on staff. They use the same criteria for membership, character, competence, experience, judgment, training, exact same information. The surveyor will verify there is either a board or something that identifies that individual in writing. They want to see documentation and verify that they've determined the categories of eligible candidates and that their operating policies have been updated to reflect those responsibilities. You also want to, they will also verify the staff is operating under current bylaws that have been approved by the board. And I'm going to use board and individual to be the same thing, just for ease of this program. You want to see documentation that the board is involved in the day-to-day operations and that they're fully responsible. And that could be the minutes. Now, a good question came up recently. It says, well, we've been told that the person here isn't supposed to be involved in going around and doing all this stuff and really hands-on, you know, they designate that or delegate that to others. They can, they can if they want, but they have to know what's going on within the hospital. And some of the criticals that I have surveyed, they're there, you know, they have daily meetings and it's usually an individual. So they know what's going on in that hospital. Also, they'll make sure they, this person, the body has periodically appraised the staff, that there's an evaluation of the patient care services, peer review, for example. They'll verify there's right criteria for appointments and something the critical also must do is they have to report changes to the state agency. First off, who's responsible for medical direction? In other words, if you have a change in the medical staff leader, you have to report that to your state agency. And the same with the person who's responsible for the operations, let's say your individual who's been appointed as opposed to a board. The surveyor is going to ask how you implement policy and procedures. How do you report those changes? Don't say who, but how soon? And that should be as soon as the change occurs, you want to report that so you're not cited if it goes too long. And that's what you want to include in your policies. Who's going to do it? What's the designation of that person? That could be your privilege and credentialing coordinator who is responsible or someone on your administrative staff. Now there's other sections where leadership has responsibility. And as we've gone through all of these sections and these sessions, you've heard about this. This is a very involved list and it really applies to whether acute or critical. The governing body, the leadership must be involved in QAPI. They have to know what's going on, what are the issues at hand. Patient rights, they must make sure that patients are cared for in a safe environment. Medical staff is qualified because they appoint them to the staff. They have to make sure there's a director of nursing. That radiology, those services are performed in a safe manner. Same with nuke medicine. That organ procurement, the contracts are in place and it's done and they're following up. Surgery and anesthesia, that we are providing these services in a safe manner by qualified individuals and that there's proper equipment. That discharge planning is being done appropriately. Our infection prevention control and ASP program is functional and it's working and that issues are being timely brought up to the board and it can also go through QAPI. Utilization review is done. Even food services because the board appoints the director of food services. Emergency services are in place and outpatient services. The board isn't just doing budget and doing operational plans. They are heavily involved in each and every component that occurs within that hospital. I'm going to flip over now to contracts. Deficiencies, again, weren't too many but I've lumped them into contracted services, the best way to put it. Again, contracted services. Some of the deficiencies, they didn't monitor. Had no idea. We have a contract for that? I didn't know that. There wasn't even a description in a contract on what was going to occur. They weren't monitored by QAPI. They didn't keep a list of contracts. They had no idea what was really out there. They weren't all in one spot. Not all hospitals identified were even on the list. Yeah, we have a contract. No, it's not on your list. They didn't do performance indicators. They didn't take that list of contracts and make sure that any performance indicators that the board was aware of them or even the medical executive committee when it had to deal with a physician performance. Inadequate telemedicine contracts. These were those that were just really basic. You will do this and we'll pay you or make sure you get paid. They didn't make sure personnel who were doing those contracts were safe. Agency nurses was a big one that they didn't make sure that these contracts between those agencies met with all the requirements of what had to be in there. They didn't review them. They didn't ensure them they were performed in a safe and effective manner. They didn't have metrics spelled out and they failed to also make sure that the company that was taking care of the controlled substances actually destroyed them because they hadn't been in that particular case. Then just some others where deficiencies in specific services. You can see it's everything from interpreters to laundry to dialysis. There are many actually for dialysis. Now, the one thing this last bullet on here, the ED physicians didn't have ACLS. That was in the contract that they had to have it. That's not part of the conditions of participation. I wanted to point that out. Question number three, Lindsay. Okay, let's get that one pulled up on your screen here. All right. Let's see here. Let me launch this question. There it goes. It took a second there. You should now see this one on your screen that says our hospital contracts for the following services. Again, you can check all that apply here to your organization. Emergency room services, laundry, laboratory, pharmacy, hospitalists, security, housekeeping, and other. I want to point out a little bit to see those other options. This is for all hospitals, not just critical. This is for all hospitals. That's what that question was designed to approach. I don't see any pending questions at this time. I know we're about maybe about halfway through. If you have any questions, make sure that you are typing those into the Q&A option or the chat. I know Laura will be happy to answer any questions that you have. Okay, we've gotten some good varying responses here. I'll go ahead and share those results. Everybody. Okay, laundry. That's very common. Yeah, hospitals. And security. I'm surprised. I would have thought security been more, but that's okay. I'm just, observation. Okay, so here's what the surveyors can do when they walk in. First off, they want to see a list of all your contracted services. That's what they want to see the list, along with everything else they want to see. They want to see your bylaws, your infection control plan, who do you have, and what do you provide by contract or by your employees. Here's just a list of some of them that you may have as far as a list. Remember, review this list to make sure it is current with whatever you do contract, because during the review session, you want to make sure you also provide them with the actual contracts, because they want to find out, did they address patient care? And if so, then okay, good. But it's the governing body involved. Does it go to QAPI? Are other conditions of participation? Are those requirements being met with this contracted service? Because the board is responsible for those services. Doesn't matter if it's your employees or contracts. And they have to make sure, the board has to make sure your contractors are doing their job so that first off, the hospital meets a participation. And that can be if you even have shared services, those especially related to patient care. Sterilization, that's one that sometimes gets hospitals, because they're sent out and they come back and they're not done right. Now joint commission, here's a little bit different. CMS, they cover everything. Joint commission, their standards only talk about patient care contracts. They won't talk about contracts involving tree trimming, cleaning your sidewalks, only patient care contracts. So that's a bit of a difference. The board has to act and make sure these things act or occur under your QAPI, because that's how you're assessing what's going on within your hospital, whether it's by your employees or your contractors. And then the board has to step up and really take action to identify those problems. Make sure first off, there is correction and that we're monitoring it and that it's working and that they're sustainable. Now joint commission, again, has more detailed section on contract management in the leadership chapter. I touch on these as we get near the end of the program. If you have services under contract, again, the board has to make sure they're done safe and efficiently. Indirect relation arrangements, take into consideration also if you're doing a joint venture. Shared services, maybe you're going to lease a part of your hospital out or a section of the building for other providers. So make sure that that's taken into consideration. Of course, formal contracts. Safe and effective, what does that mean? Well, that if you're providing safe and effective services under contract, they're subject to the same requirements as those that are provided by your employees. They don't get any special dispensation. They have to meet the same expect quality for that service. And that again, it is provided safe and effectively. So they want to see your plan. Are you looking and evaluating each service? That's why when I listed all those out at the beginning, that's just the touch of the beginning of some of those services. Because nursing could be very vast. So could be some of your new med procedures. Maybe you're doing interventional radiology. They could be, again, a large list that you have to keep. So here's just an example. You contract for imaging services. And so what are you looking at? You want to look at monitoring. How many times did something get taken to the scanning room that wasn't supposed to be there, like a walker? How many burns did you have? Hearing damage as a result of an MRI. Those of you who've had it know exactly what that's like. Compliance with training, whether it's CMS or joint commission. Completing that screening form. That the individual who's doing it and the person who's reading it, they're credentialed. They know what they're doing. Now, I just want to point out one thing. As far as that screening form, just as an aside, take a look at that. There's been some information lately, patients who don't want to change clothes, especially for outpatient MRIs, and that they might be having something within their clothing that could be magnetic or affect the MRI. So as far as your screening form, just as an aside, make sure that's included in there. Keep a list of all contracts. You must do that. They must comply. Make sure your contractor is complying with the conditions. So you may want to put that into part of the contract. These are the requirements that you must meet in order to maintain this contract and that they agree to follow them so that you as a hospital can meet those requirements. The surveyor wants to see your list of contracts and that there is a delineation of what is the contractor required to do and how are they going to then communicate that to the hospital, is that the board, whoever. Now, I do want to make one thing. As far as contracts, you can have, it's okay to have, say, pharmacy, the director of pharmacy who works with a compounding pharmacy in developing or approving that contract, looking at the contract, but the board has ultimate responsibility for that contract. Where you keep that contract is up to you. You need to have a list. There's no question about it. You have to have a list of that contract and you may want to put in there where it is, who's responsible, where is the contract maintained, when was it last reviewed, like a spreadsheet. That's a good way to keep an eye on who you've got. But you can have others involved in the actual contract making. Really quickly on co-located hospitals, you're on the same campus, you share space, maybe you share staff. Criticals aren't included in this because of your location issues and where you have to be located. But you can share staff, it does require clear lines of authority, and each hospital has to show that they are compliant with all of the conditions of participation. I did include in here, this is not in Appendix A. Again, it came out in 2019, but we still, 2021, but we still don't have it. So, again, this is one where they're working on it. Briefly, I do want to go back to compounding pharmacy. There is an OIG report that came out because it had to do with a compounding pharmacy. Contaminated injections were purchased or obtained from the standalone pharmacy. And that does, now you want to include in there that you have a right to inspect the pharmacy. If you are outsourcing them, the surveyor wants to see that contract. I would put that right in there, that you have a right to have your pharmacist go in and inspect it and make sure everything's good. OIG, also at the Office of Inspector General, they may want to see that contract too. They even have sections on questions that you want to ask about it. That's Medicare oversight, and it includes, again, the right to inspect the pharmacy. The OIG can go in and inspect the pharmacy. So there's just some examples of what extent there will be oversight for those standalone compoundings. Okay, contracts for critical access hospitals. Again, very few tag numbers because you'll probably do a lot of this with your outsourcing, whether it's lab, radiology, telemedicine, like contracting. They also want to see a list of all your contracted services. They want to make sure procedures are there to guarantee that if you use employees that work under that contract, that, yes, indeed, they are licensed. I'm thinking agency nurses, thinking contract for your telemedicine services. And they also talk about contracts in the maintenance section on equipment, testing, and inspection. You may contract this out, the criticals, if you don't have that biomed department. If you are contracting out, you can have an agreement for telemedicine, for other services that are provided. They just have to participate in Medicare to provide those services. If you are using this, and especially for an entity, the entity itself does not have to be Medicare participating, but they can still provide telemedicine services. That's a little freestanding entities or a non-Medicare participating hospital. So that would fall under the entity section. But overall, really, the agreements need to describe what are your routine procedures. And there are evidence that the governing body is responsible for the service, that they are revised, so that if the service changes, that the contract is going to change. And that the services are provided meeting acceptable standards of practice. So, again, if you're using hospitalists, the agreement says that they will abide by the acceptable standards of practice for hospitals in providing care. Like acute, the critical access hospital governing body acts through their QA program to assess whether it's direct or by contract. They look and identify quality issues. They put and make sure corrective actions are in place, that it's monitored, and it's sustainable. And the surveyor will make sure that applicable suppliers participate in Medicare, with, again, the exception of your telemedicine entities. As far as any providers, you have to have an agreement with at least one physician, MD or DO, so that they can provide care. If you don't have it in writing, I want to point this out, most of the things you'll want in writing. But if you don't, you have to be able to show that the physicians who are providing care to your patients are accepting them when you refer them out or over wherever they happen to be. In short, they've been given an appointment, and they are actually seen. Have those policies and procedures, so when you have to discharge a patient who needs more care, that you know how it's going to happen. They're going to be referred to this physician. How many times? You can put that in your contract. The surveyor will verify you do have such an arrangement, and especially if they're not available at your hospital. If they're not in writing, then how do you make sure this patient had an appointment and was seen? Do they address referral of discharged patients? And do those who handled discharges, do they know what's in that policy and procedure? How did you make sure? Do you just don't want to tell the patient, go and make a call and get an appointment? That might be one where we make the appointment for the patient, and then we just verify whether or not they showed up. Lab and imaging, a lot of times this may not be available to the extent that is needed. You do have to provide very basic labs. You do. That's for the immediate diagnosis, like maybe your chem panel, CBC, whatever it is, that you have to provide those. You can have a contracted service that comes in and runs those tests. If that's not in writing, again, especially for imaging, make sure they were seen, they had the imaging service done. If you do a contracted lab, the current CLIA certificate or waiver to do whatever tests they're doing, you want a copy of that CLIA certificate. Keep that within the contract. And, of course, they have to meet the requirements under their code. There must be evidence that you have that with you. So, again, get a copy of that CLIA certificate and keep it with your contract. Policies for additional or specialized lab services at least address where it's going to occur, who's going to make the collection, how are you going to preserve the lab, how is it going to be transported. Make sure you're getting the report back. All of that fun stuff. That could be drug testing. That could be DNA testing, whatever it happens to be. Your staff can draw it, but then make sure the agreement is clear on everything, really. Who's going to draw it, how it's going to be sent out, how you're going to make sure it's viable until it gets to that reference lab. For radiology services, same thing. You have to make sure they're done by qualified personnel and safely. So make sure you also include that you will get a copy of the report and the specified time. Doesn't have to be, again, in writing, but it's always best to have these things in writing because then if something slips through the crack, you can have a basis to say we need to reevaluate our contract because you're not meeting the expectations. How are you going to receive these reports? And that also goes for lab. Is it going to be by email? Will it be by phone? Don't forget to address your critical values. Who's responsible and how is it going to occur? I think this is our last polling question. Lindsey, you want to pop that up for me? Absolutely. I'll read this part first and I'll put the options up here for you. This says that Center Hospital is a critical access hospital that recently closed their food services. And the question is, what can Center Hospital do for nutrition services? And so let's go ahead and get that question up here for you, for you to select your responses here. The first option is close. Without food services, it cannot continue to operate. The second is contract with a nearby restaurant owned by a friend of the CEO for whatever it can provide for Central Hospital or contract with a local restaurant but must ensure nutritional needs for all patients are met. I see lots of resounding responses here to this question. That's good. There's one question here, Laura, that asks, does the list of contracted services need to include MOUs and MOAs? It would be in your best interest, yes, to have that handy. Because if they're going to be, you know, providing services through the MOA, MOUs, it's best to have it. I had a friend who worked with the VA hospital here, and she was also at another hospital, and she was the coordinator for nursing care. And they did have that in one of their lists of contracts for nursing services, that there was that written agreement or that memorandum of understanding for that care. I don't see any other questions, but I'll go ahead and end this and just show this result here. Okay. What, nobody wants to contract with the friend? Come on. Wise move. Very wise move. Okay, so food. You have to provide food so we keep these patients healthy to meet their needs. You can do it in-house or you can contract out, but that's fine. You just have to make sure we're meeting their nutritional needs. And they have to be provided according to policy and procedures. Now, there's one exception. If you are grandfathered for a co-located critical access, they will assess the co-located facility. So that's just if you are grandfathered in and there must be documentation of that and state blessing and all that fun stuff. So as far as what you have to have, you still have to have your list of all services. Describe the scope and nature of what you're providing. Who is going to do it? Is it onsite or offsite? Any limit on that service? Is it volume, frequency? When will this service be available? Because for food and nutrition, people come in at all hours of the day. And you may have to give them something to eat. Maybe you're providing surgical services at your critical. Well, they're getting back to the floor. They're hungry. How are we going to provide them food? How often will this occur? What if, you know, what are you going to do if it's bad weather? You still have to feed the patients and your staff. And then are they going to come, is this, hey, it's a restaurant and they have enough people that they can send over to the hospital. Are they going to prepare it under your building and your equipment and your supplies? Or is someone going to have to go over, get the food, then bring it back and warm it? How are you going to keep it warm? There's a lot that goes into food and nutrition, when you think about it, if you're contracting out. In this circumstance, Central did contract with a local restaurant. And the restaurant understood this is what they had to meet in order to meet those expectations. And surprisingly, when CMS showed up, they actually went to the restaurant to check it out, to make sure it was clean, sanitary measures were being met, food was stored properly, it was cooked properly. It was interesting, a little unsettling for the restaurant, but they did show up to make sure everything had been done. You have to have someone who's, of course, responsible for the operation of your hospital. And that's all inpatient services. Usually that is your CEO, whether it's by direct or by contract. So this person or whoever it is, has to make sure they give you services. So you, as the hospital, comply with all the conditions and the standards. And they also have to make sure that they're taking actions to make sure that occurs. So your CEO has a lot to do. As far as services, direct patient care, but others, your environmental situation. Is it clean? How about housekeeping? Is your laundry being done? Pharmacy services, do you have enough medications? Are you getting those medications filled timely? Instrument cleaning, sterilization, lab, you name it. They are, again, responsible to make sure it's occurring and done safely. They will ask the CEO to show how you do that. How do you provide oversight of your contracts, especially for patient care? That could be, I go through the contracts annually. I meet with the individual heads of those services, like lab or pharmacy, and we go through the contract and determine is there anything we need to change or do we need to go look for a new provider? How do you make sure there is compliance with the metrics, even, or bylaws to make sure that those are also being met? So CEO for your criticals, they have got a lot on their plate for contract management. I'm going to move over to joint commission in their contract management. Again, I mentioned there were a few areas that they had a little bit more information than what CMS provided. They have the key sections that talk about effective performance of leadership, structure, relations, culture, but operations. Under operations is where they put contract management, and that's for meeting patient needs. For structure, again, it's the responsibilities or accountabilities, the CEO's responsibilities, and medical staff also. On relationships, it talks about your vision and goals. Conflict amongst leaders, joint commission adds that. CMS is silent on it. When they talk about conflict management, in between leadership groups, when the board and the medical staff aren't seen eye to eye, they also talk culture of safety and using that data, how you're going to plan your organization completely across it, management of change and performance improvement, staffing, safety, service and process design, even a safety program, clinical practice guidelines. Again, there's a lot that goes on. But for operations, administration, again, that's your C-suite. I've listed out what those elements of performance are. They talk ethics, ethical issues, and meeting those patients' needs. As far as needed services, of course, we have to do those to meet the patient population. Your leaders will decide and work on every aspect. How does it impact what we're going to do? Do we provide it directly or indirectly? Do we have the resources to support it? And at the same time, maintaining patient safety, care quality, and giving treatment and services. So as far as needed services, the needs of the population, we talk about going through contractual arrangements along with everything else. Psychiatric hospitals with deemed status, they also mention if you do or do not provide it, that's a needed service. You can provide it by contract. The standard only applies for those relating to services for patients. So what they're talking about here, joint commission, they don't talk about anything that is not patient care related. Also, you do not take any consultation or referral agreements. I find it very surprising. They didn't include those because it's part of a hospital operation. There are 10 elements of performance. There's a very extensive rationale. I'm not going to go through it in very big detail because we've touched on it. Leaders are the driving force behind the hospital, whether it's culture or how you operate. And who does it? The expectations is that they set out performance that should really reflect just basic principles of care, whether it's safety, infection prevention, reducing risk, performance improvement. They don't prescribe how you evaluate services, but they do have a few suggestions that they list out. Talking to staff. Auditing records. Looking at incident reports, that's always a good one, as long as you can get your staff to complete them. Look at reports from the contractor. Make sure they are giving you periodic reports. You can also look at the satisfaction surveys. The satisfaction surveys can also give some good information. Leaders need to decide, are they going to continue with this contract? Do you need to renegotiate it? Do you need to terminate it? But you also have to make sure we don't interrupt care and services that they do continue. For example, anesthesia, dialysis. That's always a big one. We save time and money. We also make sure we're guarding against liability exposure that really we didn't have anything to do with. And reducing conflict and, of course, litigation. They give us some definition of what a contract is. I'm not going to go through this word to word, but we know it's an agreement between at least two people for services to be performed. And they do talk about a written agreement. And that's defined in a contract or something in writing. Like somebody had mentioned that memorandum of understanding. That's considered a contract under joint commission. As far as contracted services, that's where it's not within you. It's another agency or organization or body, a person. And it spells out what's going to happen. And that's on behalf of you as the organization. And how much is it going to cost also? And that's defined in a contract. And that's defined in a contract. That care is provided. Clinical leaders and medical staff. They can provide advice on what services are out there. And the hospital describes in writing. With this contract. What's going to occur. The nature and scope. Designated leaders approve it. They monitor the contracts because they set out those expectations. Those elements, those metrics. And that's defined in a contract. And that's defined in a contract. If you have deemed or not deemed status. If you don't have deemed status. So that when you contract with another accredited organization. Services provided offsite. You still want to verify that. Anybody who's doing it for your patients. They're trained. They have privileges. They're providing care and treatment. And that's defined in a contract. If you have deemed status. The governing body can monitor those. Contracted services. But leaders are expected to monitor contracted services. Put them in writing. What are the expectations? Written description of the expectations. Make it just part of the agreement or an addendum. If you need to. There are monitoring expectations. Leaders are expected to monitor how they are acting. And that's defined in a contract. That the pharmacy company carries. Agreed upon limits at your liability limits. Those who are providing are licensed. We aren't following federal and state laws. Think controlled substances. That maybe they attend that the director can attend the meetings. For this pharmacy service. Leaders take steps to improve them. Maybe they're going to. More to monitoring. You like the company. They're having some bad moments. Maybe they're just not living up to snuff. They're not accomplishing what's in that contract. Maybe we need to renegotiate it. Put penalties. And there, if they don't complete it, sometimes you will see that with. Reconstruction. Or new construction. Where they have a timeframe in order to get this accomplished. And maybe under what terms are you. The contract. If you do. We just have to maintain continuity of care if you do happen to have to terminate them. We talk in here about reference and contract labs. They have to meet all the requirements and keep evidence of their CLIA certificate. For dean status, originating site, they have that written agreement that that distant site is a contractor to the hospital, that they furnish services so that the originating site that you comply with the conditions of participation. And that you make sure through the written agreement that all of the telemedicine providers, they go through the exact same process as we've already talked about within the CMS conditions of participation. So just briefly, if you choose to use telemedicine, that your medical staff and the board accepts their privileging and credentialing decisions, and that you grant privileges to those other providers to do just that. That's what they're providing is telemedicine services. So it's really pretty much word for word what's in the CMS conditions. I'm gonna briefly go through DNV. DNV is a Danish-based type accrediting organization. They are an accredited provider through CMS, and they have really good information on conditions of participation. Pretty much they mirror it. I've got the list here. You can go online, you can download this. It's free. The revisions last came out in January of 2023, and I checked yesterday, and that's still, because sometimes they put in a change, and so I always like to go in. So really, you evaluate services by external providers. You do it through quality management oversight. You have established measures, like you do at least once a year. And look at those high-risk areas, maybe a little bit more, and what are your metrics that you're gonna use to measure their performance. Governing Body reviews them at defined intervals, so we do provide safe and effective care. That they are responsible, again, for all services, doesn't matter if it's direct or by contract. They help and ensure that you meet your requirements and criteria for performance and re-evaluation. You have to establish those. That's your metrics, how often you're gonna do it, and what are you going to expect from them. Keep a list of all your documents, whether it's an individual or a company, and that spells out what's the scope and nature of all those services. Like the CMS and Joint Commission, they have issues, excuse me, information on telemedicine. They moved it. It had been in the Governing Body area. It is not there now, so now it's in the MS. They ensure there's a written agreement that spells out everything that that other contractor, they provide services so you comply, that you grant privileges to those providers based on the medical staff recommendations, and that you can rely on their privileging and credentialing. Let's see what else here that, again, you have relied, there we go, additional requirements. That hospital has to be Medicare participating. If that's not, and you're using physicians, that they are privileged, again, to provide the service. If you're using the hospital, get a list of those physicians and what their privileges are, and that they hold a license in the state. You have to have also evidence of external review if there's been any issues or complaints. A surveyor will determine what services you do provide, what's the scope of responsibility. They'll look at the contract, does it talk about criteria for selection and revaluation, and they will verify the organization has a way to do it. How are we going to look at these contracts and at what intervals? Now, I'm just going to talk some very general guidelines for contracts. You will look at your processes, how and who is going to be monitoring these contracts. Again, make sure you have your list of contracts, review of performance expectations. Those go to the board. Reflect them in your board minutes. Make sure all contractors are properly licensed and credentialed and privileged if necessary. Include a requirement that in your contracts that the services they provide are done in a safe and effective manner. Have a comprehensive list of all services provided by that contractor, and what are the expectations, goals, the objectives, benchmarks, so to speak. And make sure that, and you might want to just spell it out in there, that they will meet and make sure that all laws and accreditation standards are met, whether it's joint commission or DMV, CMS, that they are going to apply by all hospital policy and procedures as applicable, that contracts meet the conditions of participation, that they have a language about performance expectations. Maybe you want to have them give you regular reports, just spell out, okay, how often is that to occur? Look at the reports from the contractor. Somebody needs to be reviewing them and have the responsibility for follow-up. Maybe you want to log, like I mentioned before, the contract, what's the expiration date, who's going to review them, who has quite ownership, so to speak, over that contract. And it's a good idea to keep them on one location because if one's in pharmacy and one's in lab and one's in somewhere else, and the board has no idea or can't get access to it, that's going to be a little inefficient. That's why it's best to have them all in one location. If you want them electronic, sometimes that's better. Someone in charge of contracts that own it, do that when you make that determination, when you're entering the contract, who's going to look at the evaluation and make sure that contractor is competent, they're doing their job. Managers also, can they sign off on contracts? What is their threshold amount in dollars that they can contract with? That they're aware of what the requirements are, also under CMS. And maybe you want senior management to look at those, or, and I would always suggest this, use your legal counsel, because there could be a provision in there you're not aware of that puts you at high risk and exposure. And maybe a committee. If you've got so many of them, it does help. Have a form for that evaluation process, so they're all looking, doing the same things and evaluating. Maybe a department lead can help with that review. And have any right concerns in writing to that contractor, so you have a paper trail of when issues do crop up. Otherwise, make sure that there is a process, a list of all contracts that do affect patient care. They really need to go also to the medical executive committee. A checklist will again help, so that we're reviewing in consistent manner for that contract. That there's full cooperation, that if y'all decide you're gonna part ways, how will you make that smooth transition? And that the hospital, you might wanna consider this, you can terminate without cause and without liability upon reasonable notice. In other words, that this contractor just isn't living up to the expectations. And that there's a provision that the hospital has reserves the right to terminate without cause within 30 days notice to that contractor. And you may wanna include in their provision that you can terminate immediately if the actions of that contractor really adversely impact patient care or safety and or even safety. So make sure your legal counsel has those provisions. And then what is the contractor gonna do to make sure that they're going to follow up on their responsibilities? They're doing background checks on their employees that maybe drug screening, what is the job description, competency evaluation, I'm thinking clinical staff who are providing these services, validation of skills lab or training. So I've just got in here a contract list, pretty much says everything that I've already gone through, systematic method for contract storage, periodic review, including risk and legal, corporate name, make sure it's the right one on the contract, who is going to verify or make sure there's a provision that state law is going to govern, which state law. If you're using a contractor, you wanna make sure your state law applies, that amendments are in writing and signed by the appropriate personnel, that they state which portions are no longer valid if you are doing amendment and what must be in writing, any changes must be in writing. If you're gonna cancel it, again, 30 days notice, way to flag that, oh, this is coming up for renewal. Do you have any automatic renewal that Evergreen provisions? Make sure they're favorable to you at the hospital. Insurance provisions, who is going to be responsible for what? How much do you require them to carry in liability coverage? Is there a hold harmless indemnification? Is that mutual hold harmless? You don't wanna have to pay for someone else's mistake. And do you require proof of insurance? It's always easy to get that certificate of coverage as far as how much, that's up to you. And when you're working in areas or it happens to do with like cleaning up down limbs or doing yard work, you're even redoing your sidewalks, keeping those clean, who's gonna be responsible for personal injury or damage in the performance of those duties? And do you need to be named as an additionally insured in that contract? Limits of liability, you can talk about what are the minimum limits? Do you have a internal system to make sure you have those certificates of insurance and that the renewal information is received as long as the contract's in effect? Because if you have a process going on for years and years and years, you wanna make sure they're maintaining that coverage of their insurance. Don't forget your HIPAA agreement for your business associates. I would suggest keep a contracts or list in one spot, identify the owner. And again, who is going to sign off on how much? So, oh, good, we got a little time. We can go through this one. So here's our last situation. We have a hospitalist group. They do inpatient coverage and they include MDs, DOs and APN, Advanced Practice Nurse. They are 24 seven. They include emergency room response. They conduct pre-employment. The group does their pre-employment background checks with limited peer review once every three years. So we have a physician. They hired this doc on in August and they were to begin coverage after the background checks were completed. Now the review of his file did say he's had several, he's been around over three years. There was a gap from November to the previous year until July of the current year. So let's say he had a gap from November of 22 to July of 23. And the idea, the explanation that the doc provided was that, well, I did volunteer work overseas. Okay, that's very possible. So these hospitalists, they were 10 on and then they're done for the month. Nice work if you can get it. This physician, the first month, he was under proctorship that according to all pre-employment agreements. So the first month went by no incident and released from what they called probation. So he was good to go. Three months after that, the nursing staff kept reporting they couldn't reach Dr. Baker when they needed him and mostly on the night shift. The concerns were voiced to the medical staff, further review requested by the CMO. And they did show that the gap was because actually he was inpatient for a substance use disorder treatment. That was his gap. So he ended up leaving the hospital as employer before they got peer review done. Okay, so any citations you think hospital is gonna be getting? Is there a lack of oversight? Insufficient wording? Follow-up on care incidents with that service? Anything else? You think they're gonna run into any problems with this event? Now, granted again, peer review did a little bit deeper dive than what the actual hospitalist group did when they found out problems. And so, yeah, thank you, Lindsay. So with that, again, we got lots of good time here. Maybe if nothing else, you'll have time to go get another cup of coffee, and you'll have a little bit more time back for your day. So Lindsay, I'll leave it to see if there's any additional questions. Perfect. I do see Sarah Levy putting in your response here to this final discussion. So while you continue to do that, if you have any also final questions for Laura, go ahead and be typing those into either the Q&A option at the bottom of your Zoom window or here in the chat. And we did have one other question that came in that asks, do you consider equipment services and maintenance to be subject to this? And it's the LD4-0309 as contractual agreement for care. That's a good question. What kind of equipment? I mean, if we're talking a ventilator, yeah, I would think so. They mentioned specifically, for example, call light, X-ray equipment, OT cylinders, et cetera. Yes, yes, yes, yes. Because yeah, with your radiology equipment, that usually has to be done. That's very, they're very tight on that, on who gets to do it. You know, somebody really has to know, like a physicist for your X-ray equipment, your biomedical equipment that touches or affects patient care, call lights, that's kind of hard because, I mean, is it going off or is it an electrical situation? So that could be a little bit different. When in doubt, I would include it. So you're not missing, you're not falling through that gap that you don't wanna be cited on. I did find it interesting that Joint Commission did specify that they only relate to those that address patient care, where CMS was silent, and meaning it's probably a lot broader under CMS. And remember, if you have deemed status, they still have to meet the expectations for CMS. I don't see any other opinion questions, but I'll go ahead and end this final discussion here and we can share those before we do some final comments. Oh yeah, anything else? And so I'd be curious to know. Yeah, this was, everybody nailed it, perfect. Yeah, they're pretty much gonna be in prom because they didn't keep an eye on the contract once every three years. CMS suggests once review every two years, and this was every three years. Not enough as far as how did you vet this person? Why did you not dig deeper, finding out more? That was their privilege and credentialing. And then following up on the issues with that. When the nurses started reporting some problems. Now, just for some information, I did mention that memo on nurse midwives. So I wanted to include that. That is how you would find it. I'm not gonna go through all these, what, 12 left over? I've just got some examples in here. I try to put in things that are free that you can tap into. Those samples, that's exactly what it is. Just a sample to get you started, if nothing else. I don't promote or endorse any of them as far as which one you should use. As far as this situation, he did have some issues. Yes, it was a substance use. And the problem was with, you know, when we have our NPDB and we have an actor that we're really concerned about, we need to really make sure we're following up on those gaps in their practice. Because, okay, maybe they went back to school. Okay, fine, you can confirm that. That's great if they're going back for more training. But they had to get that training somewhere and you can be able to track that back. It's when you can't track it back that it gets suspicious, that you wanna be able to make sure you've got someone safe. And, you know, do your due diligence when they do say, hey, I was at this hospital and this hospital, to make sure you're doing it appropriately. We don't wanna have to send off a bad actor that perhaps could go to another hospital and cause injury to a patient. So just make sure that you work with your legal counsel when you've got this gap and find out, okay, what can we do? What can we not do for reporting purposes? He did leave before they got it done. And to my knowledge, the last I had heard, he wasn't able to get re-licensed in the state where he was located in this hospital. So with that, Lindsey, I guess I'll turn it back to you to close this out. And again, if anyone has questions after the fact, get them to Lindsey, she's real good about forwarding them to me and I'll get back to you as soon as possible. I will be out just for those of you who do have questions. I am out for a couple of weeks, but I'll be back June 1st. Perfect, thank you so much, Laura. I did go ahead and post just some additional comments there for you on the chat as a quick reminder, if you have not joined one of our sessions before and not necessarily familiar with the process, you will receive an email tomorrow morning to the email address that you registered for today's webinar. So, but just know that it will come from educationnoreplyatzoom.us. And so because it comes from that Zoom email account, it very well may get caught up in your spam, quarantine junk folders. So if you don't see it in your inbox in the morning, I would suggest checking those additional folders. And then if it's still not there and you'd like to access the recording, we do record these sessions as on demand, meaning that you can use the same Zoom link to access both the live session and the recording. And then just remember that the recording is available for 60 days from today's date. And then we do have an additional security measure in place to make sure that we're protecting Laura's intellectual property that she's presented for us today. So when you click on that Zoom link, you will need to enter your information that will prompt an email to come to us for approval. And we approve those requests once validated very quickly, typically within just a few moments but we ask that you give us one business day to grant those approvals. And then again, you will have full access to the recording for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura presented for us today. But I did go ahead and provide that link to the slides there for you in the chat so you can have that as a resource now as well. And then if you are joining us as a member of the Georgia Hospital Association, please pay special attention in that email to the link to the survey and that is how you will obtain any continuing education credits. If you're joining us as a member of a partner hospital association, I would encourage you to reach out to your contact or your state hospital association to obtain any further information regarding CEs for this session. Now don't see any other pending questions. So as Laura mentioned, you can always submit those to us at education at gha.org. We'll be happy to get those over to Laura. And she is just wonderful about being very timely and thorough in her response. I know she did mention that she will be out of town for the next several weeks, but if you have those in the next couple of days, I would say that you can get those over to us and she'll be happy to respond. And thank you all so much for joining us. I will give you back about 15 minutes of your morning this morning and just thank you for joining us. We look forward to having you back with us for future sessions. As always, thank you so much, Laura, for your time and information. I hope you all have a wonderful day. Thank you. Thank you, everyone. Bye-bye. Bye.

Laura Dixon

risk management

patient safety

healthcare governance

compliance

laws

quality patient care

governing board responsibilities

contracts

effective communication

external patient care services

contract management

quality standards

safety standards