contract management and vendor oversight: regulations and management oversight

Marianne Klaas, RN, MN, Marianne Klaas, RN, MN, CHSPCHSP

Swedish Medical CenterSwedish Medical Center

Administrative DirectorAdministrative DirectorAccreditation, Safety, Injury Management, Accreditation, Safety, Injury Management,

and Clinical Patient Relationsand Clinical Patient Relations

Contract Management and Contract Management and Vendor Oversight:Vendor Oversight:

Regulations and Management OversightRegulations and Management Oversight

AcknowledgementAcknowledgement

VHA Program 5/29/12VHA Program 5/29/12 Sentara- Norfolk, VirginiaSentara- Norfolk, Virginia St. Lukes’s – Boise, IdahoSt. Lukes’s – Boise, Idaho

Center for Medicare and Center for Medicare and Medicaid Services (CMS)Medicaid Services (CMS)

482.12(e) Standard: Contracted Services482.12(e) Standard: Contracted Services The governing body must be responsible The governing body must be responsible

for services furnished in the hospital for services furnished in the hospital whether or not they are furnished under whether or not they are furnished under contracts. contracts.

The governing body must ensure that a The governing body must ensure that a contractor of services (including one for contractor of services (including one for shared services and joint ventures) shared services and joint ventures) furnishes services that permit the hospital furnishes services that permit the hospital to comply with all applicable conditions of to comply with all applicable conditions of participation and standards for the participation and standards for the contracted services.contracted services.

CMSCMS

The governing body has the responsibility for The governing body has the responsibility for assuring that hospital services are provided in assuring that hospital services are provided in compliance with the Medicare Conditions of compliance with the Medicare Conditions of participation and according to acceptable standards participation and according to acceptable standards of practice, of practice, irrespective of whether the services are irrespective of whether the services are provided directly by hospital employees or indirectly provided directly by hospital employees or indirectly by contract. by contract.

The governing body must take actions through the The governing body must take actions through the hospital’s QAPI program to: assess the services hospital’s QAPI program to: assess the services furnished directly by hospital staff and those services furnished directly by hospital staff and those services provided under contract, identify quality and provided under contract, identify quality and performance problems, implement appropriate performance problems, implement appropriate corrective or improvement activities, and to ensure corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective the monitoring and sustainability of those corrective or improvement activities. (See 482.21 QAPI.)or improvement activities. (See 482.21 QAPI.)

The Joint CommissionThe Joint Commission

LD.04.03.09: Care, LD.04.03.09: Care, treatment, and services treatment, and services provided through provided through contractual agreement are contractual agreement are provided safely and provided safely and effectively.effectively.

Contracted ServicesContracted Services

The same level of care should be deliveredThe same level of care should be delivered Governing Body / Leaders provide oversightGoverning Body / Leaders provide oversight The contractual agreements are those for The contractual agreements are those for

hospital’s patients.hospital’s patients. Contracts for consultation or referrals are Contracts for consultation or referrals are

not subject to the requirements in Standard not subject to the requirements in Standard LD.04.03.09.LD.04.03.09.

The expectations for the performance of The expectations for the performance of contracted services should reflect basic contracted services should reflect basic principles of risk reduction, safety, staff principles of risk reduction, safety, staff competence, and performance competence, and performance improvement.improvement.

Methods for OversightMethods for Oversight Leaders are expected to select the best methods for Leaders are expected to select the best methods for

their hospital to oversee the quality and safety of their hospital to oversee the quality and safety of services provided through contractual agreement. services provided through contractual agreement. ReviewsReviews Direct observationsDirect observations AuditsAudits Incident reportsIncident reports Periodic performance reportsPeriodic performance reports Collection of efficacy dataCollection of efficacy data Performance indicatorsPerformance indicators Staff inputStaff input Patient satisfaction surveysPatient satisfaction surveys Risk managementRisk management

CMS- TJC CMS- TJC CrosswalkCrosswalk

CMSCMS 482.12 (e)(1) 482.12 (e)(1) The The governing body governing body must ensure that the must ensure that the services performed services performed under a contract are under a contract are provided in a safe provided in a safe and effective manner.and effective manner.

(e)(2) The hospital (e)(2) The hospital must maintain a must maintain a listlist of all contracted of all contracted services, including services, including the scope and nature the scope and nature of the services of the services provided.provided.

TJC LD.04.03.09 EP4 TJC LD.04.03.09 EP4 Leaders monitor Leaders monitor contracted services by contracted services by establishing expectations establishing expectations for the performance of the for the performance of the contracted services. Note contracted services. Note 3: The leaders who 3: The leaders who monitor…are the monitor…are the governing bodygoverning body

EP2 The hospital EP2 The hospital describes, in describes, in writing,writing, the the nature and scope of nature and scope of services provided through services provided through contractual agreementscontractual agreements

EP3 Designated leaders EP3 Designated leaders approve contractual approve contractual agreementsagreements

Clinical vs. Non-ClinicalClinical vs. Non-Clinical

CMSCMS 482.12 (e)(1) 482.12 (e)(1) The governing body The governing body must ensure that the must ensure that the services performed services performed under a contract are under a contract are provided in a safe provided in a safe and effective manner.and effective manner.

(e)(2) The hospital (e)(2) The hospital must maintain a list must maintain a list of all contracted of all contracted services, including services, including the scope and nature the scope and nature of the services of the services provided.provided.

An An inventoryinventory of contract of contract services that affect the services that affect the quality and safety of quality and safety of patient care (clinical and patient care (clinical and non-clinical) should be non-clinical) should be developed and developed and maintained.maintained.

Using hospital defined Using hospital defined “Inclusion and Exclusion” “Inclusion and Exclusion” criteria to identify criteria to identify relevant contracts and relevant contracts and include on the hospital's include on the hospital's inventory ONLY those inventory ONLY those contract services that contract services that meet the Inclusion meet the Inclusion criteria.criteria.

Inclusion vs. Exclusion Inclusion vs. Exclusion CriteriaCriteria

Inclusion Criteria: Those contract services that contribute to the quality and safety of care, treatment and services including contract services with staff associated. Examples:

Clinical Care Medication Management Physician Services (patient care) Purchased Labor (patient care) Affiliation Agreements (patient

care) Translation Services (Deaf Talk/Interpretation Services) Entire Department Contracted

Exclusion Criteria: : Those contract services that do not contribute to the quality and safety of care, treatment and services. Examples:

Cable TV Vending/ATMs Lawn Services and

Maintenance of Plants/Flowers

Lease agreements

TJC- LD 04.03.09

LD.04.03.09 EP1- 4LD.04.03.09 EP1- 4Contracted ServicesContracted Services

1-Clinical leaders and medical staff advise on the sources of clinical services to be provided through contractual agreement.

2 - The hospital describes the nature and scope of services provided through contractual agreements.

3 - Designated leaders approve contractual agreements. 4 - Leaders monitor contracted services by establishing

expectations for the performance of the contracted services.

Note 1: In most cases, each licensed independent practitioner providing services through a contractual agreement must be credentialed and privileged by the hospital using their services following the process described in the “Medical Staff” (MS) chapter.

Note 3: The leaders who monitor the contracted services are the governing body.

LD.04.03.09 EP 5-7LD.04.03.09 EP 5-7Contracted ServicesContracted Services

5 – Leaders monitor contracted services by communicating the expectations in writing to the provider of the contracted services.

Note: A written description of the expectations can be provided either as part of the written agreement or an addendum.

6 - Leaders monitor contracted services by evaluating these services in relation to the hospital's expectations.

7 - Leaders take steps to improve contracted services that do not meet expectations.

Examples of improvement efforts to consider include the following:

Increase monitoring of the contracted services. Provide consultation or training to the contractor. Renegotiate the contract terms. Apply defined penalties. Terminate the contract.

LD.04.03.09 EP 8-10LD.04.03.09 EP 8-10Contracted ServicesContracted Services

8 – When contractual agreements are renegotiated or terminated, the hospital maintains the continuity of patient care.

10 - Reference and contract laboratory services meet the federal regulations for clinical laboratories and maintain evidence of the same. * *: For law and regulation guidance on

the Clinical Laboratory Improvement Amendments of 1988, refer to 42 CFR 493.

LD.04.03.09 EP 23LD.04.03.09 EP 23Contracted Services Contracted Services

(Telemedicine)(Telemedicine) 23 - For hospitals that use Joint Commission accreditation for

deemed status purposes: The originating site has a written agreement with the distant site that specifies the following:

The distant site is a contractor of services to the hospital. The distant site furnishes services in a manner that permits the originating site to

be in compliance with the Medicare Conditions of Participation (Appendix A)

The originating site makes certain through the written agreement that all distant site telemedicine providers’ credentialing and privileging processes meet, at a minimum, the Medicare Conditions of Participation at 42 CFR 482.12(a)(1) through (a)(9) and 482.22(a)(1) through (a)(4). (See also MS.13.01.01, EP 1)

If the originating site chooses to use the credentialing and privileging decision of the distant-site telemedicine provider, then the following requirements apply:

The governing body of the distant site is responsible for having a process that is consistent with the credentialing and privileging requirements in the “Medical Staff” (MS) chapter (Standards MS.06.01.01 through MS.06.01.13).

The governing body of the originating site grants privileges to a distant site licensed independent practitioner based on the originating site’s medical staff recommendations, which rely on information provided by the distant site.

Det Norske Veritas Det Norske Veritas (DNV)(DNV)

DNVDNV

So Easy? So Easy? So Far From It!So Far From It!

Oversight Issue #1Oversight Issue #1

Contracted Services’ own Contracted Services’ own accreditation and accreditation and certificationcertification Validate currency Validate currency ““Meets all applicable Meets all applicable

standards”standards”


Direct Direct ObservationObservation After hoursAfter hours WeekendsWeekends


Documentation Audits:Documentation Audits: Vendor may use different formsVendor may use different forms Vendor may lack details/specific for Vendor may lack details/specific for

tracking and tracingtracking and tracing Vendor may not have access to electronic Vendor may not have access to electronic

medical recordmedical record Vendor forms may be scanned into the recordVendor forms may be scanned into the record

Not documented, not doneNot documented, not done


Incident Reporting StructureIncident Reporting Structure If asked to produce any If asked to produce any

incident reports based on incident reports based on contractor/vendor, could you?contractor/vendor, could you?

Role of risk managementRole of risk management How can staff/medical staff How can staff/medical staff

report issues for tracking and report issues for tracking and trending? (ends up via QAPI)trending? (ends up via QAPI)


Timely Timely reviewing of reviewing of periodic periodic reports reports submitted by submitted by the individual the individual or organization or organization providing the providing the servicesservices


Trust but Trust but verify that the verify that the organization is organization is collecting data collecting data that addresses that addresses the service the service efficacy.efficacy.


Human Resources: Human Resources: Monitoring Monitoring contracted contracted services can be services can be challenging challenging because people because people doing the work are doing the work are not direct not direct employees of the employees of the organization.organization.

COMPETENCY!COMPETENCY! ““Trust but verify”Trust but verify”


Sub-contracting:Sub-contracting:No contractor should be sub-No contractor should be sub-contracting their work without your contracting their work without your express consent and knowledge.express consent and knowledge.Sub-contractors must meet same Sub-contractors must meet same performance metrics.performance metrics.Audit for any variances e.g., a different Audit for any variances e.g., a different dialysis machine suddenly shows up dialysis machine suddenly shows up (substituted) from a sub-contracted (substituted) from a sub-contracted vendor.vendor.


Review patient Review patient satisfaction satisfaction surveyssurveys

Bottom LineBottom Line

Highly regulatedHighly regulated Specifics for being compliantSpecifics for being compliant Daunting scopeDaunting scope Quality and patient care at Quality and patient care at

stakestake Financial gains possible Financial gains possible

(reducing contracts; patient (reducing contracts; patient satisfaction)satisfaction)

Thank you!Thank you!

contract management and vendor oversight: regulations and management oversight

Documents

hospital services

safety of services

scope of services

shared services

contractor of services

medicaid services cms482

hospital staff

cmsthe governing body