As the 2017 UNOS Transplant Management Forum rapidly approaches, I've been reflecting on the impact Extract has made with our transplant customers over the last year. It seems like yesterday that I was writing my reflections on UNOS TMF 2016 (you can read that here).
In most healthcare institutions, medical procedures are associated with orders or encounters. An order (or standing order) can be defined as rules, regulations, protocols, or procedures prepared by the professional staff of a hospital or clinic and used as guidelines in the preparation and carrying out of medical and surgical procedures. An encounter can be defined as a health care contact between the patient and the provider who is responsible for diagnosing and treating the patient.
So, you're thinking of migrating to Epic's solid organ transplant module Phoenix? Or did you recently switch? The Phoenix product has come a long way since its initial release around 10 years ago. It is a great way to effectively manage your transplant population within the fully-integrated Epic suite of products. I helped to support the first 40 or so Phoenix go-lives during my Epic tenure and take great pride in the application.
How do your objective measures and process improvement plans fit together in your Quality Assessment and Process Improvement Program (QAPI)? Are they all individual efforts, kept in binders and not communicated to the various stakeholders? Or is your QAPI program a vibrant living entity in which all stakeholders are actively engaged? One of the key items that the Centers for Medicare and Medicaid Services looks for is a clear, cohesive and implemented plan that is reflected in your QAPI policy and it is a lack of this that is frequently cited as a deficiency during a CMS audit.
In our last blog, we discussed the development of objective measures in your Quality Assessment and Process Improvement (QAPI) program and using a SMART approach as described by Doran in Management Review in 1981. Today, we are going to focus on some additional considerations and discuss how to manage these measures so as to yield demonstrable and actionable improvement through the use of process improvement projects.
In our first blog of this series, we discussed the model framework for developing a Quality Assessment Process Improvement program. Today, we will discuss how to develop objective measures that are used in three of the aspects of the program, namely Feedback, Data Systems and Monitoring; Systematic Analysis and Systemic Action; and Performance Improvements. The directive to emplo y objective measures is provided in the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (§482.96(a) Standard: Components of a QAPI Program) that states...
In our previous blogs, we have reviewed some aspects of transplant operations, how to stay compliant and how to address concerns raised by regulatory agencies such as the United Network for Organ Sharing (UNOS) and the Centers for Medicare and Medicaid Services (CMS) when issues arise. Our next series of blogs will focus on how transplant programs can proactively track their progress and address potential problems before theybecome major issues. During this series, we will review the structure, operations and tools of an effective Quality Assessment and Process Improvement Program (QAPI). First, let’s review the 5 aspects that create the conceptual framework for a QAPI program under the Medicare requirements.
Once again I had the pleasure of attending the 24th Annual UNOS Transplant Management Forum for my 4th time earlier this year. As always, it was a flurry of learning, knowledge-sharing, networking, and well-deserved awards for leaders in the industry.
It was as apparent this time as it was every time before, that the transplant community is a close-knit group who all struggle with similar things regardless of their geographical location. These struggles span across many areas, including financial, staffing, regulatory requirements, lack of organs, information technology, reporting, managing the constant deluge of paper, and many more. While I can't claim that Extract can help with all of these, there are two specific struggles that we excel at fixing: extracting discrete results from faxed external lab results and intelligently splitting, classifying, and filing large documents (such as referral packets) into patients' charts.
Previously we have discussed in general what happens when your center comes under regulatory scrutiny and what you can expect. Today, we will begin to look in greater detail at what a System Improvement Agreement (SIA) entails, the items that the hospital commits to fulfill and some strategies for addressing them.
The System Improvement Agreement (SIA)
In our previous post, we discussed what happens when your program receives a letter from either the United Network for Organ Sharing (UNOS) or the Center for Medicare and Medicaid Services (CMS) and your program's initial response. Today we will focus on what happens if CMS does not accept your mitigating factors application.
Should you receive a letter from the Centers for Medicare and Medicaid Services (CMS), the focus will likely be on a failure to meet one of the Conditions of Participation, most likely related to either graft or patient survival relative to expected results. Under the authority of 42 CFR §488.61, a transplant program may request that CMS consider mitigating factors in the re-approval process. There are three general areas that will be reviewed to determine whether a program can be approved based upon mitigating factors. These areas include, but are not limited to, the extent to which the outcome measures are met or exceeded, the availability of Medicare-approved transplant centers in the geographic area or extenuating circumstances that may have a temporary effect on the program's ability to meet the Conditions of Participation.