In Part I of this series, “Is Your Interventional Lab Compliant?” we posed questions to help Cardiology, Radiology, and Interventional Lab Directors determine whether their Diagnostic, Interventional, and Electrophysiology Labs were in compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs).
Although an Interventional Lab may appear compliant at first glance, compliance is a complex issue—and it’s likely that you answered “no” to one of our questions.
If so, don’t despair. Here are five steps you can take to bring your Interventional Lab into compliance.
Familiarize yourself with the Conditions of Participation for Surgery and Anesthesia.
Conduct a gap analysis to determine deficiencies.
Develop a plan that establishes processes, policies, and procedures to address deficiencies. But don’t reinvent the wheel—look at what is already established within the surgery department at your facility. (This is also a good time to make sure the surgery department’s processes, policies, and procedures reflect CMS expectations.)
In most cases, processes, policies, and procedures can be adopted in the lab with little to no revision. In addition, collaboration with the surgical department will help ensure that the same level of care is established.
CMS spells out the specific policies and procedures expected to be in place. Review the post-procedure report. Does the report include all of the elements required by CMS, such as estimated blood loss?
Develop a communication plan for and implement the changes to address the deficiencies. A physician champion can encourage medical staff buy-in. Additionally, support from senior leadership is essential as new processes are introduced.
Education related to the CoPs might also be needed. Organizations accredited by The Joint Commission (TJC) tend to focus their energies toward compliance with TJC standards, with little to no regard for the CoPs. Although TJC standards and CMS CoPs have recently become more closely aligned, differences do exist.
Recent examples of CMS action towards hospitals that have been found out of compliance with the CoPs might also be helpful in motivating adoption of the new processes.
Develop a plan to monitor ongoing compliance. Too often, organizations will implement processes to address deficiencies, only to discover—often at the hand of an outside reviewer—that after time goes by, the processes are no in place or in practice.
CMS expects hospitals to be compliant with the CoPs 100% of the time. Establish frequent reviews early on in the change process. Once performance is at full compliance, establish a process for periodic reviews.
As time passes and 100% compliance continues, the time between reviews can be lengthened. However, if at any time during the review process, performance is not at 100%, the frequency of reviews should be increased. Compliance should be reported through the QA/PI process, including reports to the Governing Body.
Never assume that you are in compliance—take steps to make sure you are in compliance.
If you have questions about compliance in your organization’s Interventional Lab, send us an email or call our office at (513) 241.0142.
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