The Centers for Medicare & Medicaid Services (CMS) is testing a new way to evaluate the effectiveness of accrediting organizations (AOs), using direct observation of the AO’s survey of a hospital instead of through the traditional validation survey by state survey staff within 60 days after the AO survey. The Wisconsin Division of Quality Assurance (DQA) informed WHA of the change and asked WHA to alert its members so hospitals are aware that multiple teams, DQA and AO surveyors, might be on-site during an inspection. DQA understands that having multiple survey teams on-site could be problematic for some hospitals and accordingly will work to minimize any disruption to the normal operation of the hospitals affected by the pilot.
The complete notice from CMS Region V (Pam Thomas, Manager, N-LTC Certification & Enforcement Branch) regarding this change follows:
Pilot Testing Direct Observation for AO Validation Surveys
CMS is testing a more streamlined, efficient way to assess AOs’ ability to ensure that facilities and suppliers comply with CMS requirements.
CMS evaluates the ability of AOs to accurately assess providers’ and suppliers’ compliance with health and safety standards through a validation survey process. Historically, CMS has measured the effectiveness of AOs by choosing a sample of facilities, performing state-conducted assessment surveys within 60 days following AO surveys, and comparing results of the state surveys with the AO surveys. In a pilot test, CMS will eliminate the second state-conducted validation survey and instead use direct observation during the original AO-run survey to evaluate AOs’ ability to assess compliance with CMS’s Conditions of Participation.
Direct observation will enable CMS not only to evaluate AO performance more effectively, but also to suggest improvements and address concerns with AOs immediately. This approach will relieve providers from having to undergo the burden of a state’s follow up assessment. The approach is another example of the wide-ranging effort at CMS to eliminate duplication and relieve burden, reducing the amount of time that healthcare facilities must spend on compliance activities.
CMS will also analyze and incorporate State complaint investigations of accredited facilities as part of the agency’s strengthened validation program. This work will focus on identifying and monitoring accredited facilities that are out of compliance with Medicare health and safety requirements. CMS will use this information as an additional indicator of AO performance.