Transcript Quality Healthcare

Surviving Survey and
Re-certification
Mississippi Stats
◦ 116 Hospitals
◦ 163 RHC’s (MSDH website)
◦ 28 CAH’s (35miles or “necessary provider”)





Recertifying approximately 6-7 years
Survey will be unannounced
Survey will be during RHC posted hours
Usually 1 surveyor
4 to 8 hours
Rural Mississippi

Frequently Requested Items
◦
◦
◦
◦
◦
◦
◦
◦
◦
Providers hours
Proof of Physician review of mid-level charts
Personnel list and licenses
Proof of Mid level involvement in policies
Policy and Procedure Manual
Fire Marshall Inspection
Medical Director
Clinic owner demographics
Lab tests available at the clinic
What to expect upon arrival








Compliance with laws
Location
Physical Plant
Organizational Structure
Staffing and Staff Responsibilities
Provision of Services
Health Records
QAPI – Program Evaluation
Conditions for Certification
Compliance with State practice acts
concerning mid-levels
 PA’s -The supervising physician shall
review all patient encounters not later
than 24 hours after the physician
assistant has seen the patient.

Compliance with Laws









NP’s –
1. Review by collaborative physician of a random sample of charts that
represent
10% or 20 charts, whichever is less, of patients seen by the nurse
practitioner
every month. Charts should represent the variety of patient types seen by
the
nurse practitioner. Patients that the nurse practitioner and collaborating
physician
have consulted on during the month will count as one chart review.
2. The nurse practitioner shall maintain a log of charts reviewed which
include the
identifier for the patient’s charts, reviewers’ names, and dates of review.
3. Each nurse practitioner shall meet face to face with a collaborating
physician once per quarter for the purpose of quality assurance and this
meeting should be documented.
Compliance with Laws
Location of Clinic

Safety
◦
◦
◦
◦

Exit signs
Evacuation routes
Fire Extinguishers
Covered outlets
Preventive Maintenance
◦ Bioengineering logs
◦ Drugs and Biologicals

Non-Medical Emergencies
◦ Things likely to occur in your location
◦ Documentation
Physical Plant
Medical Direction
 Written Policies

◦
◦
◦
◦
◦

Administrative (authority and responsibilities)
Patient Care
Personnel
Fiscal
Maintenance
Disclosure of Names/Addresses
Organizational Structure

Sufficient Staffing
◦ Reasonable time to discharge responsibilities
◦ Loss of mid-level or physician (waiver)



Must be available to furnish services all times
the clinic is operating as an RHC (posted
administrative hours)
Mid level must be present 50% of the
operating hours of the RHC
Written documentation of physician review
Staffing and Staff Responsibilities






Primarily engaged in providing RHC services
at least 51% of the total operating schedule
Patient Care Policies – (written guideline for
medical management)
Referral Policies
Description of Services
Additional Services furnished through referral
Drugs and Biologicals
◦ Storage – Outdated – deteriorated - security
Provision of Services
Records kept at the clinic
 Record retention (6 year) RHC reg…
 Appropriate release of information
 Protection of Record Information

◦ Ensure confidentiality
◦ Provide safeguards against loss or
unauthorized use
Patient Health Records

Annual Evaluation
◦ Total operations including
 Organization
 Administration
 Policies and Procedures
 Personnel
 Fiscal
 Patient care areas
Program Evaluation

Quality Assessment Performance Indicator
(QAPI) system in place that is appropriate to
the complexity of the RHC operations, data
driven, and focused on improving outcomes
in patient safety, quality of care and patient
satisfaction. The QAPI program must include
objective measures for at least four
organizational processes and clinic utilization.
The key requirement is documenting that a
system is in place.
Quality Assurance Performance
Improvement (QAPI)
Contact Information
[email protected]