In our last blog, we spoke about the initial steps that you must take after you have entered the System Improvement Agreement (SIA) with the Centers for Medicare and Medicaid Services (CMS). Today, we will discuss the Independent Peer Review Team (IPRT) and the action plan that will be developed and implemented following their visit.
At a minimum, the IPRT team must include an organ specific (1) transplant surgeon, (2) transplant physician, (3) administrator, (4) coordinator, (5) social worker, and (6) Quality Assessment Performance Improvement (QAPI) coordinator. The onsite consultant should also be present in an observatory role during the IPRT visit as he/she will assist the program to create the action plan in response to the IPRT team findings.
Based upon CMS’ findings that initiated the SIA, CMS will provide a list of content and focus areas for the IPRT to review and cases on which to conduct a Root Cause Analysis. CMS will expect the IPRT to summarize review findings and recommendations that are pertinent to or potentially causal to the program outcomes. The goals of the IPRT are to:
- Identify causal and/or contributory factors that may be preventing or inhibiting the program from maintaining ongoing compliance with Medicare program requirements for hospitals and transplant centers; and,
- Propose recommendations for program changes/adjustments based on the IPR findings.
Prior to the IPRT visit, the hospital will submit to CMS the constituents of the IPRT as well as a comprehensive plan for the assessment including methodology for CMS approval. The onsite consultant will assist the program in preparing material for the IPRT to review prior to their visit. There will be a call with the IPRT and CMS to review the goals of the visit. Following the visit the IPRT team will author a written report of the findings as well as have a conference call with CMS to report their findings and recommendations. Based upon the IPRT findings and recommendations, the onsite consultant will assist the program in creating an Action Plan that must be submitted to CMS for approval and implementation. Towards the latter portion of the SIA, the program must provide evidence to CMS that all of the action plan items have been implemented.
When choosing a company to facilitate your SIA, it is important to choose one that has the ability to provide insight on how to successfully implement recommendations in your institution.
In addition to the IPRT visit and implementation of their recommendations, the SIAwill require your program to perform certain other assessments and analyses. One area of particular focus will be on your quality program. You will be required to submit to CMS the minutes of your monthly QAPI meetings. In addition, you will be required to submit a Baseline Quality Indicator report that describes the outcome and process indicators that the program monitored in the year preceding the SIA as well as those that will be monitored in the coming year including the source of the data, the frequency of assessment and the methodology, who is responsible for doing the monitoring, the benchmarks that will be used for comparison and the method of communication of the results and lessons learned. If your program does not have a clearly identified person to manage your QAPI efforts, CMS will mandate temporarily hiring such a person until you have one in place.
Another deliverable that will be required is a staffing analysis that the program will submit to CMS describing the analytic results from the analysis and a comprehensive description of any resultant actions. The analysis will be performed to:
- Compare staff member activities to job descriptions and to core program needs to ensure accountability is established for critical tasks and to identify possible gaps in patient care processes; and,
- Assure that each staff member is appropriately trained and credentialed to perform the tasks in their job description, including ongoing training/updates appropriate to each staffing category.
The final requirement is to demonstrate proficiency in analysis of SRTR reports. To accomplish this, the program will need to demonstrate proficiency in pulling the appropriate program and patient-level files from the SRTR; performing appropriate mathematical or statistical analyses; displaying information in useful ways (tables, graphs, or narrative); and, interpreting and applying the information in meaningful ways. The analyses will identify the actual and expected graft survival rates for patients in the most recent Program Specific Reports from the SRTR, for the following subgroups: 1) any subgroup identified in the SIA; 2) by transplant surgeon and 3) by transplant physician. In addition, if the program had applied for mitigating factors, the requested factor should be analyzed within the context of the SRTR data.
There are several other reports that are required as well as the final call with CMS in order to successfully complete the SIA. We will cover these in our next blog.
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About the Author: Dr. John Daller, MD, PhD, FACS
As a former Director of several transplant programs, Dr. Daller has expertise in all aspects of transplant program management, as well as hospital program development including clinical, regulatory, business and administrative leadership via his company Strategic Illuminations. He consults in the area of medical legal review, due diligence and scientific evaluations, as well as utilization review via Daller Consulting. He is also Chief Medical Officer of Concordia Valsource, LLC which provides consultative services to developing biopharmaceutical companies and to Venture Capital groups investing in the health and life sciences. Previously, Dr. Daller was Vice President for Medical Programs in the Transplant Business Unit of Genzyme Corporation.