Though Centers for Medicare and Medicaid Services (CMS) expectations for Anesthesia Services have changed little over the years, these Conditions of Participation (CoPs) were recently revised and published in Transmittal 59 dated May 21, 2010. This four-part series outlines compliance challenges associated with the new CoPs and solutions to help hospitals assess vulnerabilities in anesthesia and sedation activities.

Responsibilities of the Anesthesia Services Department
While many hospitals view Anesthesia Services as primarily a Medical Staff department, like Surgery or Gynecology, the CMS Conditions of Participation view it as similar to departments like Radiology, Food and Nutrition, and Rehabilitation Services. The emphasis lies in the provision of services rather than the positioning or reporting responsibilities set forth on an organizational chart. The Anesthesia Services department provides anesthesia, sedation, and analgesia as defined in Part I of this series. Staffing includes anesthesia providers, along with technicians or support staff members who assist in the management of the department. As a department of the hospital, Anesthesia Services has similar responsibilities for meeting the needs of patients, and improving care through the QA/PI process. Additional responsibilities are specified in the regulations.

Responsibilities of Anesthesia Services Director
The regulations require the Medical Staff to establish criteria for the qualifications of the Director of Anesthesia Services. The Anesthesia Services director is responsible for:

• Developing policies and procedures governing the provision of all categories of Anesthesia Services, including under what circumstances an MD or DO who is not an anesthesiologist, a dentist, oral surgeon or podiatrist is permitted to administer anesthesia
• Defining the minimum qualifications for each category of practitioner who is permitted to provide anesthesia services
• Integrating Anesthesia Services into the QA/PI program of the hospital

Required Policies and Procedures
The goal for delivery of anesthesia services centers around consistent use of resources to meet patient needs. Policies outline these expectations, and at minimum, hospitals must address:

• How Anesthesia Services needs will be met at all locations
• Delineation of pre-anesthesia and post-anesthesia responsibilities
• Delivery of anesthesia services consistent with recognized standards-well designed policies would likely include:
  • Patient consent
  • Infection control measures
  • Safety practices in anesthetizing areas
  • Protocol for supporting life functions (cardiac, respiratory and hyperthermia emergencies)
  • Reporting requirements (errors, incidents)
  • Documentation requirements (both in the medical record and other sources such as narcotic logs)
  • Equipment requirements (monitoring, inspection and maintenance)

Tips for Compliance
To comply with this section of the regulations, changes in policies and practices may be necessary. Begin by assuring the following has been established in policy or practice:

• Assure that Medical Staff documents clearly delineate the required items for privileging physicians and others for the types of anesthesia and complexity of procedures.
• Review policies to assure that each item noted in the Conditions of Participation can be found. If policies reside in a general or nursing manual, consider utilizing a quick reference sheet to be able to quickly identify the location and content required by the regulation.
• Conduct an internal review of all sedation and anesthesia locations to assure consistent standards among all locations. Utilize pharmacy billing records, if needed, to identify all areas where sedation or anesthesia may be provided, particularly in off-site locations.

This series of articles provides a guide to the most important aspects of the new regulations. When modifying your current practice, please refer to the full text of the regulations.

The next article in this series, “Take a Deep Breath: New CMS Anesthesia Regulations,” will tackle Pre-and Post-anesthesia Evaluation. If you have questions about this series or any CMS regulation, please contact Cary D. Gutbezahl, MD, Chief Executive Officer of Compass Clinical Consulting at (513) 241.0142.