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Hospital Accreditation

Contract Services - Part Four
Posted by
on 6/23/2020 10:00:00 AM
Welcome to the last in a four part blog series on CMS' expectations for managing contract services in a hospital. In this blog, we're going to discuss CMS expectations for integrating oversight into your hospital's quality assessment and performance improvement (QAPI) program.
CMS' Conditions of Participation at §482.12(e)(1) require that your hospital's governing body "ensure that the services performed under a contract are provided in a safe and effective manner". The governing body has the responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of Participation and according to acceptable standards of practice, irrespective of whether the services are provided directly by hospital employees or indirectly by contract.
In addition, CMS (§482.21) requires that your hospital's governing body must ensure that your QAPI program reflects the complexity of your hospital's organization and services; involves all hospital departments and services - including those services furnished under contract or arrangement - and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. Failure to include contract services can result in a Condition Level deficiency!
So here's a few tips to assure that contract services are effectively integrated into your QAPI program:
  1. Assure that the evaluation of each contract service is formally reported to an entity that is part of your QAPI program. It is not acceptable to have an evaluation performed administratively in a department and not report into the QAPI program. For example, if quality reports on your hospital's contracted linen service are sent administratively only to the Director of Materials Management, and not reported also through your QAPI program; CMS will consider your hospital non-compliant.
  2. Assure that the data collection methodology and frequency is consistent with the expectations of your QAPI program. CMS will expect you to oversee contract services no differently than had your hospital provided the service directly. For example, if your QAPI program calls for reporting no less frequently than quarterly, then there should be evidence that contract services are reported into the program on a quarterly basis as well.
  3. Assure that your governing body receives regular reports on the quality and safety of contract services. Again, the frequency and specificity of reports should be no different than what is provided to your governing body surrounding services provided directly by your hospital as outlined in your QAPI plan.
Following these simple rules will assure that your hospital's oversight of contract services is effectively integrated into your QAPI program.
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About the Author

Traci Curtis RCP, HACP
RCP, HACP

Traci Curtis is the Executive Director of Survey Operations for CIHQ. Traci has more than 15 years of experience in hospital survey preparation.
Traci's past positions include Chief Quality Officer for a multi-hospital community based health system where she was responsible for accreditation and regulatory compliance. Prior to joining CIHQ, Traci served as the Executive Director of Quality for a large regional medical center, providing executive management oversight in the areas of quality, risk, medical staff credentialing, and patient relations.
Traci received her degree in education from Pima in Tucson Arizona. She is nationally certified in healthcare accreditation, and serves on the Board of Examiners for the Healthcare Accreditation Certification Program.
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