Part 5 of the “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing,” white paper.
It is not uncommon for hospital leaders to believe that this story is rare; that Medicare termination could never occur at their facilities. Administrators often think, “We’ve always done well, why would this time be any different?” However, as both The Joint Commission (TJC) and CMS become more thorough in their survey processes, this thinking may represent false confidence. The following guidelines present a strategy for dealing with Immediate Jeopardy.
Guideline 1: Create a Plan that is Realistic and Patient-Centered
CMS is especially rigorous in the survey process, which focuses on protecting patients. If the survey is being conducted after notification of Immediate Jeopardy, it is vital that measures are implemented to remove the identified immediate threat to patients. Verify that the plan reflects CMS standards and not those of other accrediting agencies such as TJC. Everything delineated in the action plan
must be realistic and attainable. CMS surveyors expect all cited deficiencies to be remedied with no errors. CMS follows a zero tolerance policy and only considers the action plan to be successful when the specified goals are achieved 100% of the time. Hospital leaders should constantly be vigilant and always aim for this outcome.
Guideline 2: Involve Your Board -Now and Always
An important lesson to learn from Haywood’s Near-Death Experience is that transparency is not a luxury but a necessity, particularly with the board of directors. The board provides oversight, direction and representation of the “true” owners of the hospital. Informed involvement of board members is a critical requirement for knowledgeable leadership.
CMS requires hospitals to have a governing body (a board of directors) that is legally responsible for the conduct of the hospital as an institution. The key deficiency cited during a complaint survey is attributed to the governing body’s role in oversight of quality care. Many boards take a “rubber stamp” approach to quality issues, often because board members lack the understanding needed to appropriately question quality data and reports, so they instead concentrate on more straightforward topics such as finance. It is the responsibility of the hospital’s administration to assist board members in mastering their roles in quality oversight through education, conferences, publications and presentations. Board members who are also clinicians are integrally important in supporting the completion of this critical board role. After board members are adequately equipped to process quality information, it then becomes their responsibility to act on the information provided to them.
Engaging the board in quality oversight can prove to be an enormous asset when handling accreditation and compliance issues. Selection criteria for board members should be outlined, documented, and followed to ensure that a board is an effective resource. Clear lines of communication should be established from the front lines of patient care up through the organization and to the board. Collaboration with a board can help prevent a Near-Death Experience like Haywood’s by addressing problems when they arise.
Guideline 3: React Quickly
If the unthinkable happens at your hospital, and Immediate Jeopardy becomes a reality, swift action is vital. Early intervention assures that your plan is ready before the CMS notice hits the papers. Follow these steps within the first 24 hours of Immediate Jeopardy notification to help avoid Medicare termination:
- Initiate a media plan, even if you think you won’t need it.
- Identify solution teams.
- Tap into your internal and external experts to clarify what needs to be done.
- Plan on responding to an Immediate Jeopardy notification within 10 days.
- Develop and implement an action plan within 7 days of notification and send it to the appropriate officials, allowing 3 days for transport.
- Alert the appropriate office that the action plan has been sent so that CMS regulators are prepared to review the plan when it arrives.
- If the initial plan is deemed unacceptable, this time-frame allows 12 days for revision of the plan and resurvey.
Being proactive about the media response to a notice of Immediate Jeopardy can help alleviate the potentially devastating consequences of a public relations nightmare. Put a plan in place and develop a clear and consistent message to deliver to all constituents including employees, news reporters, and members of the community. Be sure that the board is notified immediately, before the news reaches reporters, and be transparent with them throughout the process. Identify teams that will be adept at tackling various areas of non-compliance. Responding to a notice of Immediate Jeopardy should be a team effort, with input from members of leadership, medical staff and key employees at various levels in the organization. Consult with your internal and external regulatory compliance experts to ensure that the plan meets CMS’s requirements.
End Part 5
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