Installment 1 of a two-part blog series addressing proposed changes in hospital accreditation and regulatory compliance by the Centers for Medicare & MedicaidServices (CMS). In Installment 1, we’ll frame the current situation for you and top-line concerns and recommendations made by the American Hospital Association (AHA) to CMS. In Installment 2, we’ll do a deep-dive into those concerns and recommendations.
By JEFF LITTLE
Partner
In the foodservice industry, a restaurant manager’s bane of existence is the surprise knock on the door from a local or state food inspector – especially when it occurs during mealtime rushes when already overworked staff are working hard to keep pace with customer orders online, at the counter, and at the drive-thru window.
Typically, inspectors show up unannounced and check for all manner of potential violations ranging from improper food storage and cooking temps, unsanitary surfaces, presence of rodents/pests, staff mishandling of food, etc. – all things that restaurants fight hard to prevent or mitigate. After an inspection, the restaurant’s monthly score, in large numbers, is by law posted in a conspicuous location for all to see. Often, local newspapers and other media platforms post monthly scores which can either boost or bomb restaurant traffic.
In a post-pandemic, germ/virus-phobic world, more and more diners are paying attention to these scores.
In a similar fashion, the federal government is seeking to strengthen oversight of its accreditation standards and processes for hospitals and other healthcare facilities, as well as upping its penalties for issues of regulatory non-compliance. This has caused quite the kerfuffle in the healthcare industry for a variety of valid reasons.
In an April letter penned by Ashley B. Thompson, Senior Vice President-Public Policy Analysis and Development with the powerful American Hospital Association, to the Centers for Medicare & Medicaid Services [SMS], numerous concerns were raised about the [presumedly] well-intended plan that also presents numerous potential headaches for hospital staff who appreciate the need for accreditation and regulatory compliance but are concerned with how it may negatively impact daily operations.
Ms. Thompson wrote:
“On behalf of the nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association [AHA] appreciates the opportunity to comment on CMS’ proposals to strengthen the agency’s oversight of accrediting organizations [AOs] … However, the AHA is concerned that some of CMS’ proposed changes are needlessly punitive to hospitals and other providers.”
In its letter, AHA applauded a number of the proposed changes such as requiring AOs to use Conditions of Participation [CoP] and Conditions of Coverages [CoC] as minimum accreditation standards but raised concerns about other proposed “needlessly punitive” changes, including redundancy in government efforts to monitor CMS compliance and, of course, that dreaded, unannounced knock on the door, often at the very worst time.
[On a side note, my apologies for the alphabet soup of acronyms.]
AHA offered the following recommendations out of respect for the need for proper accreditation standards and the importance of monitoring compliance while also seeking to protect the ability of hospital staff to do their day-to-day job jobs at a high level, mostly uninterrupted.
Among AHA’s suggestions:
- Permit AOs to retain a limited number of “black-out” dates for accreditation surveys to protect time for emergency preparedness and other key activities drawing heavily on hospital staff and resources.
- Protect patient and workforce safety by allowing AOs to provide a same-day notification of the pending arrival of onsite surveyors.
- Transition to a direct observation approach for validation surveys to reduce the rework and disruption of “look-back” surveys.
- Modify its overly punitive proposal to remove the deemed status of providers following certain validation surveys.
- Clarify the circumstances under which CMS would make AO survey reports public.
- Eliminate duplicative complaint survey activity conducted by state survey agencies and AOs, which adds unnecessary administrative burden and confusion for hospitals and other providers.
None of us actually know where all this will land but it’s important to be aware of what could be, and to plan accordingly for any adjustments necessary to stay in line with new regulatory guidelines and ahead of potential violations.
Undoubtedly, there will be a number of significant changes to current standards [after all, government does seem to enjoy control], and it may well behoove you to plan early meaning now — for how you’re going to achieve that delicate balance of monitoring your own compliance and rectifying issues timely while allowing daily operations to hum along without disruption. We’ll touch on that in Installment 2.
ABOUT JEFF LITTLE
Jeff is a Partner at Excelerant Consulting and a widely recognized thought-leader in hospital supply chain, purchased services, hospital operations, facilities and construction, and medical capital equipment. He brings a deep insight and understanding of today’s healthcare environment and is well-connected throughout the industry, having worked in clinical settings within world-class hospitals, and multiple Integrated Delivery Networks [IDN] and Group Purchasing Organizations [GPO]. He is highly skilled at educating clients on subtleties and nuances of today’s complex healthcare ecosystem and excels at the development of commercial strategies.
Jeff is an active member of the Association for Health Care Resource & Materials Management [AHRMM], American College of Healthcare Executives [ACHE], Federation of American Hospitals [FAH], the IDN Summit, and serves on the board of the ACE Summit.
ABOUT EXCELERANT CONSULTING
Excelerant Consulting is the go-to organization for med-tech companies that need to position products and services successfully for Value Analysis Committees, contract acquisition, and sales modeling and execution to commercialize the launch of medical devices or services with Group Purchasing Organizations [GPO], Integrated Delivery Networks [IDN], or Regional Purchasing Coalitions [RPC]. Clients rely on Excelerant to identify their unique Value Proposition, enhance their product positioning, navigate corporate contracting opportunities, and provide sales support to accelerate growth and profits.