In our clinical consulting work, we have the privilege of serving as a trusted advisor to hospitals and health systems seeking informed guidance on accreditation and clinical compliance issues.
We work with a wide range of institutions—both in size and in resources. A significant portion of our effort focuses on hospitals experiencing close CMS examination.
A review of these clients suggests that there are common traits that may predispose a healthcare organization to CMS compliance challenges:
1. A disproportionate focus on numbers over outcomes
In their goal of "good numbers," Board members and senior leadership focus on financial and managerial control systems with less attention on the core business of clinical service outcomes. Financial results are often prioritized as first-order business while clinical quality may not be seen as high priority and, therefore, receives less emphasis. This is rarely an intended leadership result and, simply the outcome of the fiscal pressures most healthcare leaders experience. It is imperative to keep an eye steadily focused on the core mission of delivering safe care while also prioritizing financial viability.
2. Lack of frontline manager knowledge of applicable Conditions of Participation.
Frontline managers must understand how to translate the seemingly obscure Conditions of Participation (CoPs) into everyday operations. For example: the core infection control requirements may be seemingly well communicated, but does the manager of patient registration understand and implement these requirements? Does the manager of patient registration ensure that registration staff comply with requirements for handwashing and observing potential patient infection issues? Do the staff know who to notify for assistance should an issue arise?
3. Inadequate integration of Quality Assurance and Performance Improvement principles and practices with organizational operations.
Quality Assurance and Performance Improvement (QAPI) sets the goals and processes for measuring, improving, and assuring safety in patient care. When QAPI is not well coordinated with medical staff leadership, nursing, and other clinical leaders, or is overlooked when operational management is being reviewed, a disconnect can occur that allows critical data and feedback loops to go unrecognized and unanswered.
4. Failure to use Sentinel Events and near misses as learning opportunities.
Sentinel Events (SEs) and near misses happen in all hospitals with some frequency, shaking organizations to their core as an affront to their common commitment to rendering safe and effective care. Institutions that learn from these occurrences experience fewer of the same in the future. There is tremendous information to be obtained—such as through a Root Cause Analysis—that can better shape and influence clinical care across the organization. Using SEs and near misses as a way to grow organizational capacity and resilience is a hallmark of an effective hospital.
5. Low investment in education, staff development, and discovering better practices.
Most problems and opportunities have been encountered and solved before, and can be modeled for emulation for organizational improvement. But insular organizations that don't invest in continuous learning, investigation, and inquiry often fail to implement best practices and preventative programs. Leaders should continually scan the external environment for better practices and consider how to incorporate these practices into their own organizations.
6. Minimal medical staff involvement in clinical operations system design and implementation.
As the gatekeepers to care, physicians influence the safety and quality of care for patients and serve as role models for other staff in demonstrating commitment to patient care safety and efficacy. When there is minimal visibility in leadership of clinical operations, there is likely poor adherence to CoP minima, leaving organizations at a startling compliance risk.
7. Lack of feedback and action based on data.
At-risk organizations may measure everything from outcomes to throughput to patient engagement. However, it is unknown what becomes of the data once collected. Is it used to change processes, drive decisions, and alter behavior? Or is it meticulously collated, reported, and forgotten? Driving with key clinical information is an important attribute of successful organizations. After this significant data is collected, a plan of action should be developed.
8. A crisis-to-crisis existence.
An organization that consistently has all hands on deck to address the latest problem but fails to ever achieve smooth sailing commonly denotes a failure of established safe processes. Attention is focused on the issue of the day, rather than the systems, controls, and culture that reliably produce safe care. Crises occur in any dynamic environment, but an inordinate crises focus means the company never achieves "normal," outlier incidents become prevalent, and safe, reliable care cannot be consistently delivered.
9. Failure by leadership to understand and operate according to the Conditions of Participation.
The Centers for Medicare and Medicaid Services represent most hospitals' largest payer. Yet, few senior leaders acquaint themselves thoroughly with the CMS Conditions of Participation, which simply represent the contract the hospital has entered into with CMS. The organization agrees to uphold certain minima (CoPs) in return for payment for the patient care covered by the contract. The surprise in the senior ranks when a complaint or validation survey yields results indicating failure to comply with CoPs frequently demonstrates a lack of understanding of the expectations. It is unlikely that the contractual requirements of other payer sources would be similarly unknown.
These are the characteristics we frequently note when assisting an organization in CMS jeopardy. It is never ill-intent or designed incompetence that leads to the scrutiny of a hospital or health system. Rather, it is usually a matter of not having grasped the importance of compliance and hardwiring strategies to maintain compliance within daily operations. Good hospitals sometimes experience poor results, but by examining these nine common traits, healthcare leaders will be able to identify areas of vulnerability within their own organizations.
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Kate Fenner, Managing Director of Compass Clinical Consulting, has more than 35 years of experience in senior healthcare leadership roles in university, regional, state and, national organizations. Throughout her career, she has worked with and presented to hospitals on a variety of regulatory topics including performance improvement, leadership standards, human resources management, root cause analysis, and board involvement in quality. In addition, she has led and participated in dozens of mock surveys to help healthcare organizations meet the standards and expectations of regulatory bodies such as the Joint Commission, the Centers for Medicare and Medicaid Services, and state departments of health. She is a regular keynote speaker throughout the country and has authored a leading college text on law and ethics in healthcare and has co-authored other noted texts on a variety of healthcare issues.
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