Going Beyond CMS & TJC Minimum Safety Standards: The Patient Safety Assessment

Find out more
What is a CMS Systems Improvement Agreement: FAQ'S

FAQ: What is a CMS Systems Improvement Agreement?

by

The Systems Improvement Agreement (SIA) is a legal contract between a healthcare institution and the Centers for Medicare & Medicaid Services (CMS) to aid compliance with the Conditions of Participation (CoPs) in federal programs. Healthcare organizations can request to enter into an SIA with CMS if they are facing termination for Immediate jeopardy findings that have not, or could not, be fixed in the short time permitted. 

This contract between the hospital/healthcare organization and CMS binds the organization to engage in a series of improvement activities to address multiple deficiencies in compliance with the CoPs with the assistance of a third-party monitor/consultant approved in advance by the CMS Regional Office. The agreement grants the organization additional time to make sustainable improvements in complex quality, cultural, policy, and procedural deficiencies.

Compass Clinical Consulting SIA Experts in the Media:

Becker’s Hospital Review: CMS’ Systems Improvement Agreement: A Last Chance Alternative to Medicare Termination?

Written by Victoria May Fennel, PhD, RN-BC, CPHQ, Director of Accreditation and Clinical Compliance for Compass Clinical Consulting

Hospital and Health Networks Magazine: The Systems Improvement AgreementThe Centers for Medicare & Medicaid Services uses systems improvement agreements to give hospitals more time to respond to an Immediate Jeopardy finding.

Written by Kate Fenner, PhD, RN, Managing Director, of Compass Clinical Consulting

Why enter into an SIA?

Entering into an SIA provides more time for a healthcare organization to fix its deficiencies than is typically allotted from a validation or for-cause survey. In some cases, the timeframe has been extended to as long as 24 months. Of course, CMS may rescind the pending termination sooner, especially when the hospital is found to be substantially in compliance with all of the CMS Conditions of Participation.

Although there are many reasons for an organization to enter into an SIA, perhaps the most important rationale is the opportunity to take a “breather” from continuous scrutiny and compliance visits. An SIA includes an organization-wide assessment, gap analysis, corrective plan, and implementation, only resulting in a new official survey afterward. There is the time, space, and external support to address concerns, design better systems, and develop staff to meet or exceed the CMS Conditions of Participation.

Compass Clinical Consulting has a 100% success rate in removing Immediate Jeopardy findings and achieving successful Systems Improvement Agreement (SIA) resolution.

The SIA process

The SIA is a legal document and stipulates the terms under which the healthcare organization agrees to:

• Obtain independent consultative review (at its expense);
• Submit the names of the proposed consultant companies and/or individuals (including their curriculum vitae);
• Acquire expertise in the development and implementation of an effective quality assessment and performance improvement program;
• Engage the services of an independent, full-time, on-site compliance officer for the duration of the agreement; and
• Other terms specified by CMS including resurvey by CMS within six to 12 months.

In return, CMS agrees to suspend the execution of the scheduled termination order pending the healthcare organization’s fulfillment of the agreement.

The SIA specifies the qualifications and responsibilities of the independent consultant/group and stipulates the content and frequency of the reports to be submitted to CMS. Consultants’ reports are released to the healthcare organization only after CMS approves them. At their discretion, CMS may elect to discuss the findings from the reports with the independent consultant/group by phone or in person at the healthcare organization’s expense. The agreement itself is a public document — some examples of SIAs executed in the past couple of years are available on the internet. Reports from the independent consultant/group, though, are subject to federal and state privacy protections.

How does the SIA help?

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 a 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.

Takeaway: Good for patients, communities, hospitals

The tool for sustainable quality healthcare change would appear to be the longer-term implementation of oversight through an SIA as opposed to the more limited and focused response to Immediate Jeopardy findings.

Is this good news or bad? Anything that promotes compliance with minimum standards of safe care is a good thing for patients and their families. An alternative to termination is good for hospitals struggling to achieve consistent compliance and good for their communities. However, the availability of a more reasonable alternative may mean that more Immediate Jeopardy findings are made.

The publicity, cost, degree of oversight, and length of time required to fulfill the obligations of an SIA should motivate hospital leaders to avoid findings of noncompliance that result in the need for an SIA through proactive compliance efforts. Ensuring compliance is less costly than having to address it in a very public light.

Clearly, avoiding an Immediate Jeopardy finding and an SIA is the best way to go. Prevention is cheaper than the cure.

###

For more information about CMS Immediate Jeopardy and the Systems Improvement Agreement, contact us at 800-241-0142, email info@compass-clinical.com, or use our contact form below.

Share on LinkedInTweet about this on TwitterShare on FacebookShare on Google+Buffer this pageEmail this to someone