Many hospitals have experienced a finding of Immediate Jeopardy (IJ), the Centers for Medicare and Medicaid (CMS) term that notifies an institution that a threat to the health and safety of a patient (or patients) has been found on survey. Most organizations can successfully address an IJ within the short prescribed timeframe—usually 23 days. But some institutions do not successfully resolve IJ findings, or upon follow-up survey, have been found to have additional IJ conditions.
In the past, the only remedy for failure to cure an IJ within prescribed timelines was revocation of Medicare participation status—a devastating blow to a hospital’s financial and operational integrity. Recently, however, CMS has begun using a new method to gain compliance from hospitals with repeat or multiple IJ findings on complaint or validation surveys: the Systems Improvement Agreement (SIA).
The SIA is a contract between the hospital and CMS that binds the hospital to engage in a series of improvement activities to address multiple deficiencies in compliance with the CoPs. The agreement grants the hospital additional time to make sustainable improvements in complex quality, cultural, policy, and procedural deficiencies.
Typically, the SIA has several additional features beyond curing an IJ finding, including the requirement for an outside monitor or agent to assess ongoing progress and the selection of a CMS-approved consultant to 1) assist the hospital in assessing compliance with all relevant CoPs; 2) develop a plan to address required improvements; 3) provide support for plan implementation; and 4) prepare the organization for survey of all CoPs by the designated agency using the Survey Operations Manual.
The SIA approach represents an intermediate step between full revocation of participation in Medicare/Medicaid and ongoing repeated surveys and corrective actions. As such, it gives CMS a mechanism for prompting large-scale organizational change in the face of noncompliance without the drastic move of revocation. Nevertheless, an SIA requires a significant commitment of organizational resources to making sustainable behavioral changes and maintaining a leadership focus to ensure compliance with the CoPs.
With a new weapon in the arsenal, CMS expectations for correcting deficiencies may quickly become more difficult to fulfill. As a result, expect to see more hospitals agreeing to SIAs.
For more information on Systems Improvement Agreements and how Compass Clinical Consulting is prepared to help your organization respond to this new tool, contact Cary D. Gutbezahl, MD at (513) 241.0142 or visit the Compass Clinical Consulting website.
