Accreditation, compliance, and quality
There is no such thing as “partial credit” when it comes to compliance with the CMS Conditions of Participation; it’s a pass/fail effort
At A Glance
- Immediate jeopardy and sentinel events response
- Continuous survey readiness
Overview
CMS and state surveillance activities are at their highest levels in recent history. In the past six months alone, The Greeley Company has served 10 hospitals facing CMS Immediate Jeopardy situations. All 10 of the institutions had recently been accredited by independent accreditation deeming authorities.
Each of the hospitals, however, experienced expensive and demoralizing CMS challenges as a result of sentinel events or a CMS validation survey. In the words of one hospital CEO, “We were honored by a very grueling survey by CMS. Never having experienced one of these before, we were completely and utterly deflated at the end of it.” ‘
Not one of these situations occurred at a “bad hospital”; the initial outward appearance of each situation was “bad luck.” In truth, however, the validation surveys and patterns of sentinel events proved that each hospital was having trouble managing variation in its quality processes.
Our approach
Established clients of The Greeley Company know there are cost-effective ways to manage the challenges of compliance, accreditation, and quality. Our unique approach starts by directly identifying the relationships between regulations and accreditation requirements, hospital policy, and actual practice. We then work with hospitals to define the most efficient and straightforward means to achieve the objective. And because we’re completely independent of any regulatory or accreditation authority, you can be sure our opinions are objective and unbiased.
We know what CMS and accreditation authorities are looking for in their processes – and we can help you save money. We help each client design their own approach to compliance and accreditation—then help them choose an accreditation authority. Because we have extensive experience with The Joint Commission, DNV, and HFAP, and we have served hospitals in all 50 states, we know how best to design, implement, and manage accreditation and quality management processes, including assistance in managing clarifications, equivalencies, and responses to sentinel events.
Our perspective
We have seen several patterns emerge from our work in the past year. First, the states (under contract to CMS) have become decidedly more aggressive in their follow-up after reported sentinel events. Second, there is an increased level of CMS surveillance at the regional and national level. CMS regions and headquarters are now able to detect and act upon patterns of certain events, whether self-reported by hospitals or resulting from validation surveys. This pattern-detection capability has resulted in targeted surveys in classes of hospitals. For example, in 2011 there appeared to be a series of surveys and enforcement activity directed at large, urban safety net hospitals. More recently we’ve seen a sequence of activities directed at both for-profit and nonprofit hospitals within larger chains. These activities have not been constrained to either a particular state or a CMS region—we’ve seen increased activity in all CMS regions. CMS has decidedly shown that it does not prefer termination of the ability to receive Medicare and Medicaid reimbursement; instead, it appears to prefer a process of ”supervised rehabilitation,” up to and including the imposition of a Systems Improvement Agreement, or SIA.
More importantly, however, we’ve seen a trend whereby CMS and the states are conducting their surveillance operations largely independent of the non-government accreditation authorities such as The Joint Commission, DNV, and HFAP. In several situations, CMS arrived for a full validation survey shortly after the hospitals received three-year accreditations.
Our services
The Greeley Company is the largest and most experienced practice in the country dedicated to accreditation, compliance, and quality. We have the scale, depth, and geographic range to deal responsively with hospitals anywhere in the United States. Within the past year, our delivery teams have resolved some of the most serious and challenging immediate jeopardy situations facing hospitals in recent memory. Our proven approach to clinical compliance and accreditation keeps hospitals out of trouble and focused on their primary mission to deliver efficient, top-quality care.
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Immediate jeopardy and sentinel events response
The Greeley Company helps hospitals to manage clarifications, equivalencies, and responses to adverse CMS and accreditation actions and sentinel events. Decades of experience have taught us that the best way—perhaps the only way—to lead hospitals out of trouble is to quickly focus on the truly important issues and then find simple, natural ways to integrate compliance into efficient, safe, and satisfying operations. We help hospital leadership to rest assured that they will be bulletproof when CMS comes back to verify compliance. The Greeley Company’s practical tools work repeatedly to free hospitals from CMS threats and protect them from falling back into jeopardy.
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Continuous survey readiness
The Greeley Company can help you to comply with the requirements of CMS, states, and the various accreditation authorities, including The Joint Commission, DNV, and HFAP. Services include:
- Designing a customized approach to compliance and accreditation
- Assistance with selecting an accreditation authority
- Assessment of practices and documents against CMS and accreditor standards and regulations using tracers, document reviews, and interviews
- Identification and prioritization of compliance vulnerabilities for focused improvements
- Design and implementation of strategies for focused improvements
- Customized education for clinical, administrative, and operations staff on accreditation requirements and survey processes
- Interim staffing for key positions needed to support continuous survey readiness