Marianne Klaas, RN, MN, CHSP

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Contract Management and Vendor
OversightRegulations and Management Oversight

• Marianne Klaas, RN, MN, CHSP
• Swedish Medical Center
• Administrative Director
• Accreditation, Safety, Injury Management, and
  Clinical Patient Relations

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Acknowledgement

• VHA Program 5/29/12
• Sentara- Norfolk, Virginia
• St. Lukess Boise, Idaho

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Center for Medicare and Medicaid Services (CMS)

• 482.12(e) Standard Contracted Services
• The governing body must be responsible for
  services furnished in the hospital whether or not
  they are furnished under contracts.
• The governing body must ensure that a contractor
  of services (including one for shared services
  and joint ventures) furnishes services that
  permit the hospital to comply with all applicable
  conditions of participation and standards for the
  contracted services.

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CMS

• 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.
• The governing body must take actions through the
  hospitals QAPI program to assess the services
  furnished directly by hospital staff and those
  services provided under contract, identify
  quality and performance problems, implement
  appropriate corrective or improvement activities,
  and to ensure the monitoring and sustainability
  of those corrective or improvement activities.
  (See 482.21 QAPI.)

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The Joint Commission

• LD.04.03.09 Care, treatment, and services
  provided through contractual agreement are
  provided safely and effectively.

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Contracted Services

• The same level of care should be delivered
• Governing Body / Leaders provide oversight
• The contractual agreements are those for
  hospitals patients.
• Contracts for consultation or referrals are not
  subject to the requirements in Standard
  LD.04.03.09.
• The expectations for the performance of
  contracted services should reflect basic
  principles of risk reduction, safety, staff
  competence, and performance improvement.

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Methods for Oversight

• Leaders are expected to select the best methods
  for their hospital to oversee the quality and
  safety of services provided through contractual
  agreement.
• Reviews
• Direct observations
• Audits
• Incident reports
• Periodic performance reports
• Collection of efficacy data
• Performance indicators
• Staff input
• Patient satisfaction surveys
• Risk management

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CMS- TJC Crosswalk

• CMS 482.12 (e)(1) The governing body must ensure
  that the services performed under a contract are
  provided in a safe and effective manner.
• (e)(2) The hospital must maintain a list of all
  contracted services, including the scope and
  nature of the services provided.

• TJC LD.04.03.09 EP4 Leaders monitor contracted
  services by establishing expectations for the
  performance of the contracted services. Note 3
  The leaders who monitorare the governing body
• EP2 The hospital describes, in writing, the
  nature and scope of services provided through
  contractual agreements
• EP3 Designated leaders approve contractual
  agreements

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Clinical vs. Non-Clinical

• CMS 482.12 (e)(1) The governing body must ensure
  that the services performed under a contract are
  provided in a safe and effective manner.
• (e)(2) The hospital must maintain a list of all
  contracted services, including the scope and
  nature of the services provided.

• An inventory of contract services that affect the
  quality and safety of patient care (clinical and
  non-clinical) should be developed and maintained.
• Using hospital defined Inclusion and Exclusion
  criteria to identify relevant contracts and
  include on the hospital's inventory ONLY those
  contract services that meet the Inclusion
  criteria.

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Inclusion vs. Exclusion Criteria

• Inclusion Criteria Those contract services that
  contribute to the quality and safety of care,
  treatment and services including contract
  services with staff associated. Examples
• Clinical Care
• Medication Management
• Physician Services (patient care)
• Purchased Labor (patient care)
• Affiliation Agreements (patient care)
• Translation Services (Deaf
• Talk/Interpretation Services)
• Entire Department Contracted

• Exclusion Criteria Those contract services that
  do not contribute to the quality and safety of
  care, treatment and services. Examples
• Cable TV
• Vending/ATMs
• Lawn Services and Maintenance of Plants/Flowers
• Lease agreements

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TJC- LD 04.03.09
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LD.04.03.09 EP1- 4Contracted Services

• 1-Clinical leaders and medical staff advise on
  the sources of clinical services to be provided
  through contractual agreement.
• 2 - The hospital describes the nature and scope
  of services provided through contractual
  agreements.
• 3 - Designated leaders approve contractual
  agreements.
• 4 - Leaders monitor contracted services by
  establishing expectations for the performance of
  the contracted services.
• Note 1 In most cases, each licensed independent
  practitioner providing services through a
  contractual agreement must be credentialed and
  privileged by the hospital using their services
  following the process described in the Medical
  Staff (MS) chapter.
• Note 3 The leaders who monitor the contracted
  services are the governing body.

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LD.04.03.09 EP 5-7Contracted Services

• 5 Leaders monitor contracted services by
  communicating the expectations in writing to the
  provider of the contracted services.
• Note A written description of the expectations
  can be provided either as part of the written
  agreement or an addendum.
• 6 - Leaders monitor contracted services by
  evaluating these services in relation to the
  hospital's expectations.
• 7 - Leaders take steps to improve contracted
  services that do not meet expectations.
• Examples of improvement efforts to consider
  include the following
• Increase monitoring of the contracted services.
• Provide consultation or training to the
  contractor.
• Renegotiate the contract terms.
• Apply defined penalties.
• Terminate the contract.

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LD.04.03.09 EP 8-10Contracted Services

• 8 When contractual agreements are renegotiated
  or terminated, the hospital maintains the
  continuity of patient care.
• 10 - Reference and contract laboratory services
  meet the federal regulations for clinical
  laboratories and maintain evidence of the same.
• For law and regulation guidance on the
  Clinical Laboratory Improvement Amendments of
  1988, refer to 42 CFR 493.

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LD.04.03.09 EP 23Contracted Services
(Telemedicine)

• 23 - For hospitals that use Joint Commission
  accreditation for deemed status purposes The
  originating site has a written agreement with the
  distant site that specifies the following
• The distant site is a contractor of services to
  the hospital.
• The distant site furnishes services in a manner
  that permits the originating site to be in
  compliance with the Medicare Conditions of
  Participation (Appendix A)
• The originating site makes certain through the
  written agreement that all distant site
  telemedicine providers credentialing and
  privileging processes meet, at a minimum, the
  Medicare Conditions of Participation at 42 CFR
  482.12(a)(1) through (a)(9) and 482.22(a)(1)
  through (a)(4). (See also MS.13.01.01, EP 1)
• If the originating site chooses to use the
  credentialing and privileging decision of the
  distant-site telemedicine provider, then the
  following requirements apply
• The governing body of the distant site is
  responsible for having a process that is
  consistent with the credentialing and privileging
  requirements in the Medical Staff (MS) chapter
  (Standards MS.06.01.01 through MS.06.01.13).
• The governing body of the originating site grants
  privileges to a distant site licensed independent
  practitioner based on the originating sites
  medical staff recommendations, which rely on
  information provided by the distant site.

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Det Norske Veritas (DNV)
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DNV
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DNV
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DNV
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So Easy? So Far From It!
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Oversight Issue 1

• Contracted Services own accreditation and
  certification
• Validate currency
• Meets all applicable standards

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Oversight Issue 2

• Direct Observation
• After hours
• Weekends

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Oversight Issue 3

• Documentation Audits
• Vendor may use different forms
• Vendor may lack details/specific for tracking and
  tracing
• Vendor may not have access to electronic medical
  record
• Vendor forms may be scanned into the record
• Not documented, not done

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Oversight Issue 4

• Incident Reporting Structure
• If asked to produce any incident reports based on
  contractor/vendor, could you?
• Role of risk management
• How can staff/medical staff report issues for
  tracking and trending? (ends up via QAPI)

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Oversight Issue 5

• Timely reviewing of periodic reports submitted by
  the individual or organization providing the
  services

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Oversight Issue 6

• Trust but verify that the organization is
  collecting data that addresses the service
  efficacy.

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Oversight Issue 7
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Oversight Issue 8

• Human Resources Monitoring contracted services
  can be challenging because people doing the work
  are not direct employees of the organization.
• COMPETENCY!
• Trust but verify

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Oversight Issue 9

• Sub-contracting
• No contractor should be sub-contracting their
  work without your express consent and knowledge.
• Sub-contractors must meet same performance
  metrics.
• Audit for any variances e.g., a different
  dialysis machine suddenly shows up (substituted)
  from a sub-contracted vendor.

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Oversight Issue 10

• Review patient satisfaction surveys

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Bottom Line

• Highly regulated
• Specifics for being compliant
• Daunting scope
• Quality and patient care at stake
• Financial gains possible (reducing contracts
  patient satisfaction)

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Thank you!