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March 13, 2008

Quality Updates: Revised and Updated Hospital Conditions of Participation Interpretive Guidelines; CMS Hospital Outpatient Quality Reporting

There are a couple of developments from the Centers for Medicare and Medicaid Services that IHA wanted to ensure that hospitals were aware of as they have not been widely announced or publicized. The developments include revised Hospital Conditions of Participation and reporting requirements for Medicare Outpatient PPS Hospital Quality Reporting.

On February 8, CMS provided revised Interpretive Guidelines for Hospital Conditions of Participation to the State Survey Agency Directors. Please remember that the interpretive guidelines are targeted to the state and other surveyors of hospitals but are very helpful for hospitals in understanding the interpretation of the standards and the questions and methods to be used by surveyors in assessing hospital compliance. A copy of the memo and revised interpretive guidelines can be found on IHA’s web site at (click here).

There are several key revisions that hospitals should be aware of as some may require modification to your existing practices. The revisions include:

• Medical History and Physical
  Completed and documented medical history and physical no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services (482.22 (c) (5))
   
• Written Protocols or Standing Orders
  With the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved hospital policy after assessment of contraindications, orders for drugs and biologicals must be documented and signed by a practitioner who is authorized to write orders by hospital and accordance with Illinois law, and who is responsible for the care of the patient. (482.23 (c) (2)) "If a hospital uses other written protocols or standing orders for drugs or biologicals that have been reviewed and approved by the medical staff; initiation of such protocols or standing orders requires an order from a practitioner responsible for the patient’s care." Rather than an opt out policy on standing orders (exception flu and pneumo vaccines), the CMS Interpretive Guidelines call for an opting in with a practitioner signature.
   
• Additionally, for all drug and biologicals, the following elements must be present on all orders:
  - Name of Patient
  - Age and Weight, if applicable
  - Date and Time of Order
  - Drug Name
  - Exact Strength or Concentration, if applicable
  - Dose, Frequency, and Route
  - Quantity and or Duration, when applicable
  - Specific Instructions for Use, when applicable
  - Name of Prescriber
   
• Hospitals are encouraged to promote a culture "in which it is not only acceptable, but strongly encouraged, for staff to bring to the attention of the prescribing practitioner questions or concerns they have regarding orders."
   
• Verbal Orders
  Verbal orders should only be used infrequently and authenticated in most circumstances within 48 hours. Hospitals should have policies and procedures that govern the use of verbal orders and minimize their use (482.23 (c) (2) (i) and 482.24 (c) (1) (iii) All verbal orders shall be documented in patient’s medical record and signed by the individual receiving the order. "Verbal orders should be recorded directly onto an order sheet in the patient’s medical record or entered into the computerized order entry system, if the hospital employs one."
   
• Medical Records and Documentation
  "All patient medical records entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures." If a hospital uses an EHR or EMR, they must be able to establish the identity of the author of each entry and the hospital must have policies and procedures to ensure that stamps or authorizations are used only by the individual whose signature they represent (delegation to another individual is not permissible). (482.24 (c) (1))

Medical record should contain sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers by including all necessary documentation including diagnostic and lab results.

• Anesthesia – Pre and Post
  A pre-anesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia within 48 hours prior to surgery or a procedure requiring anesthesia services. (482.52 (b) (1)) A post-anesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services. (482.52 (b) (3))
   
• Securing of Drugs and Biologicals
  Interpretive guidelines on drugs and biologicals are provided on evaluating secure and locked areas and requirements for hospital policies and procedures for access to secure or locked areas.

CMS Hospital Outpatient Quality Reporting
In order to help hospitals prepare for the outpatient quality reporting starting with 2^nd quarter 2008 cases, IHA will be hosting a couple of telephone conference calls with supporting power points on Thursday and Friday, March 27 and 28. These conference calls will cover the reporting requirements for OPPS hospitals in order to receive their 2.0% increase starting January 1, 2009 for Medicare patients. While Critical Access Hospitals (CAH) have not been permitted by CMS to participate in the Hospital Outpatient Quality Reporting, they may find the educational programs helpful for preparing for the time when Medicare allows full participation by all hospitals.

While there are similar measurement reporting requirements for some of the 7 measurements required under this new Outpatient Quality Reporting, the major challenge for hospitals will be in identifying the entire population or universe that qualifies for reporting and the strategic approach to sampling if a hospital chooses to not do full reporting due to volume issues.

Unlike inpatient data which is more readily identifiable using internal hospital information systems, the outpatient population relies more heavily on diagnostic inclusions and exclusions. Additionally, hospitals will need to identify the various hospital outpatient service areas including emergency department, observation care, outpatient surgery, etc.

As Medicare will also match their hospital outpatient claims to the hospital outpatient quality reporting, it will be essential to capture all of the Medicare patients in the population. If a hospital is not using sampling, one will need to have a complete set of Medicare reported patients.

In order to help hospitals prepare for the Hospital Outpatient Reporting and to help guide them in capturing their entire universe of qualifying patients, IHA will be hosting two conference calls for IHA members at no charge. The conference calls will cover:

The Thursday, March 27 program will be held at 10:00 a.m. central time and the Friday, March 28 program will be held at 1:00 p.m.

To register for the March 27 program click here.

To register for the March 28 program click here. 

If you have additional questions, please contact Pat Merryweather at pmerryweather@ihastaff.org. Thank you.