Tag C 330 COP: Periodic Evaluation

PIN CAH CMS Standards Review Conference Call Notes

Call: Nov 25, 2009

- can draw finance dept can provide benchmarks - some facilities get utilization stats from software/TechTime - LOS benchmark is a CAH standard: the annual ALOS must be not more than 96 hrs - Maria Koslosky, Barrett/Dillon, has a sample report she

Tag C 331-332 Periodic Evaluation, Service Utilization

- Discussion re: what “total” program means - Maria Koslosky shared Dillon’s approach to content and data resources: : COMPdata (an MHA member report; contact Bob Olson or Roberta Yager at MHA) market share, current and trend over past 5 yrs : PIN Benchmarking report- LOS, days in AR : Clinical/Medical Records: mortality rate, return to ED, Cx rate, process for reviewing MR : Policies- list of changes, additions, deletions; or software that tracks the same : Quality - annual goals for improvement, National Patient Safety goals/indicators, midlevel provider reviews, level of staff participation, CMS Core Measures performance, patient satisfaction scores summary with data trend from past 5 yrs, individual department quality activities summary : Report- goes to Board, medical staff and department managers : Maria is willing to share an example of their report; Wilcox will forward to the group when she gets it from Maria - Roosevelt MC: combines the CAH Periodic Eval with the annual eval required for RHC, all at a single meeting

Responsibility for Conducting the Periodic Eval

- Roosevelt: Administrator and Business Office - Pioneer: CEO, PIC, others as needed - Roundup: QA Coord pulls together all of the info needed from others, generates report - CFVH: QIC pulls together all of the info; CFO & Risk Manager provide info as needed; she generates the report with recommendations - St John’s: QIC puts together a manual that meets all of the COP requirements - Each manager writes a quality activities summary for their dept that details staff involved, any space and/or equipment issues, improvement successes, challenges and plans for the coming year - process is aligned to coordinate with their fiscal year, so it goes to the Board in Aug, leadership completes a strategic planning retreat in Sept/Oct, an approach for the coming year is approved, then implemented - Marias MC: all depts come to a quality meeting to report, rotating reporting every 2-3 months, each one reporting once a year. Reports include their quality goals and accomplishments; include a 3 yr trended history of measures as much as possible. 1 PIN CAH CMS Standards Review Conference Call Notes

Periodic Eval Report Conclusions/Recommendations

- Roundup: are the last page of their report; improvement plans can then be updated throughout the year as needed

Tag C 333 Periodic Evaluation Open and Closed Record Review

- “Open” means the record is active, patient has not been discharged - “Closed” means the patient has been discharged - CFVH: include review of inpatient, ED and OP reviews : look at mortality rate and palliative care measures : QIC does some concurrent review and reports findings to CEO and DON weekly (ex: pneumonia care, nursing assessments) : include findings from peer review : includes other things she notices may be issues and focuses on them for a while to see if they are problems

Criteria for Record Selection

- Dahl: are so small they do 100% review of all AC and CAH-SB records; DON does the review - Roundup: CMS core measure cases, adverse drug reactions/events, nosocomial infection cases; also review for delinquent completion and complete signature authentication

Requirement for Sample to be “representative of the services furnished”

- Dillon: are also auditing records for accurate billing (RAC)

Tag C 334 Periodic Evaluation Policies Review

- CFVH: has a committee that looks at the administrative policies; they document in the committee minutes individual polices that were reviewed and action; then have a cover page for the entire manual to document review : medical staff reviews all health care provision policies; must be approved there; this meets their physician and mid-level reviewer requirement : difficult to meet the requirement for external review - St John’s : include on the policy both its original effective date and revision dates : develop a ‘retired policies manual, so that when policies are revised, you can go back and see what was in effect at any given time (important for RM, QOC investigation, staff, etc) : hang onto the retired policies as required by the facility’s ‘record retention’ policy; then destroy as described by the policy at the appropriate time - Dillon: purchased “Policy Manager Software”, partially funded by a Ship grant; works great

2 PIN CAH CMS Standards Review Conference Call Notes

- St John’s : a surveyor recommended to Barb DuMont that she keep the clinical and administrative manuals separate : manuals are sorted by department : managers come to see her each year and the 2 of them review policy changes together : per Bill Patten, plant operations, environment services, admin policies are reviewed every year in addition to the clinical policies

Tag C 335 Periodic Evaluation Conclusions

- CFVH; go to Board and PI Committee; she doesn’t always get feedback from the Board on their response; this is a problem for her - Roundup: a Board member comes to the QA meeting and meeting for the Periodic Eval; that person is her contact with the Board if she needs anything from them - Pioneer: the QIC attends the Board meetings and gets feedback directly from them; in turn, she takes their feedback to her quality committee meetings - Glasgow: their managers take turns attending Board meetings, sharing w/ them dept info

How do you demonstrate whether or not “Policies Were Followed”?

- Dillon: do QAs on assessments to verify procedures are followed - Roundup: choose 10 or so records a year and QA - Libby: the p/p review committee has a form to use for this; when the manager comes for the dept policy review, a couple of random policies are chosen to verify if a) the policy is current b) per manager’s report, staff are following it. No independent review is conducted. - Glasgow: their managers take turns attending Board meetings, sharing w/ them dept info

Next Review Call: Wed, Dec 30th, beginning at 2:00 pm, Starting with tag C-336