Healthcare Accreditation Certification Program Newsletter
July 2020


Contract Services - Part Three

By: Traci Curtis
Welcome to the third 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 monitoring the quality and safety of these services
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.
So how does the governing body assure that contract services are provided in a safe and effective manner? The simple answer is that your hospital must monitor those services. This implies establishing performance metrics that relate to the expectations you have placed on the contract entity.
For example, if one of your expectations for a contract dialysis service is that their dialysis machines are maintained in accordance with manufacturer instructions, then an appropriate performance metric could be the percentage of cleaning and disinfection activities performed in accordance with the manufacturer instructions and within a timely manner.
In another example, if you require a contract Imaging Service to perform MRI exams in a safe manner, you could monitor the incidences of untoward events such as thermal burns or hearing damage.
Once you have established the performance metrics for each contract service, you must assure that data is collected, aggregated, analyzed, and acted upon. Your hospital can either perform these activities itself require these activities to be performed by the contract service, or do a combination of the two. Remember that the frequency and methodology of data collection must be consistent with that established by your hospital’s QAPI program.
Join me in a couple of weeks for the last of this blog series as we discuss CMS’ expectations for integrating contract services into your hospital’s QAPI program.
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