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Hospital Accreditation

Autopsies - The Forgotten Requirement
Posted by
on 12/6/2016 10:00:00 AM
The hospital never saw it coming! It was the last day of survey, and the physician surveyor asked to see their policy on securing autopsies. After literally digging through old binders, they managed to find an obviously outdated document. When the surveyor asked for evidence that the hospital was implementing their policy, the survey coordinator laughed and said: "We haven’t done an autopsy here in years."
The truth is, autopsies are not as common as they used to be. Historically, an autopsy was often the only way clinicians could determine a patient’s cause of death. Performing autopsies was considered an important adjunct of care. With advancements in technology, the relative value of autopsies has waned.
Today, most general acute care hospitals - for a variety of reasons - rarely perform autopsies. Yet both CMS and accrediting agencies still have requirements addressing autopsies in their regulations and standards. So what does your hospital need to demonstrate compliance in this area? The interpretive guidance in Appendix A of the State Operations Manual at §482.22(d) forms the basis for this discussion.
Securing Autopsies
CMS expects that the medical staff "attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest." Your hospital would be well-advised to have clearly defined criteria for what is considered an "unusual death" or a death of "medical-legal and educational interest".
Many hospitals utilize their county coroner criteria to define the former, but often do not have defined criteria for the latter. Remember that you will be held to the criteria that you use. If a death meets the criteria, you are obligated to attempt to secure an autopsy, and fail to do so could result in a deficiency.
Note that the regulation does not state that autopsies are required to be performed, only that the medical staff attempt to secure one. If the family declines, or wants an autopsy but is unwilling to pay for one, the hospital is under no further obligation. There should be clear documentation maintained of the hospital's due diligence in attempting to secure an autopsy for each death that meets criteria. If the coroner performs the autopsy, an attempt should be made to obtain the results for internal review purposes.
Informing the Medical Staff & the Patient’s Physician
Should an autopsy actually be performed, CMS will expect your hospital to have a mechanism to notify the medical staff - and especially the patient's attending physician of this fact. Some hospitals have interpreted this to mean that autopsies can only be schedule in a manner that permits practitioners the ability to physically be in attendance. The regulation actually only requires notification of when an autopsy is being performed. There is no requirement to schedule an autopsy at the convenience of the medical staff or the patient's physician.
Use of Autopsy Results
Although not explicitly stated in the regulation, there is an implied expectation that the results of an autopsy are shared with the patient's attending physician, as well as the medical staff at large. This is especially true if the autopsy gleaned results that would have an educational value. There is no prescribed mechanism to do this. Some hospital's simply present the case and results at various committees, while other hospitals will incorporate the autopsy results into a more formal educational offering.
The subject of autopsies is not commonly raised during CMS or accrediting surveys, but following these simple steps will assure your hospital's compliance should the need arise.
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About the Author

Richard Curtis RN, MS, HACP

Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on the Medicare Conditions of Participation and the CMS Certification & Survey Process. As CEO, he successfully guided CIHQ in becoming the nation's 4th CMS approved deeming authority for acute care hospitals.
Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.
Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.
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