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CMS's Proposed Hospital Staffing Revisions Get Cool Reception

 |  By Margaret@example.com  
   January 03, 2012

A rule proposed by the Centers for Medicare & Medicaid Services to allow changes in the governance structure and medical staffing at hospitals has little support among the more than 100 public comments submitted.

The rule is part of an extensive CMS review of the entire set of conditions for participation (CoP) that hospitals must meet to participate as deemed hospitals in the Medicare and Medicaid programs. CoP requirements have been reviewed and revised on an ad hoc basis, but this is the first time in many years that CMS has undertaken a retrospective review of the CoP.

The proposed revisions fall into several broad categories, including governance, staffing, care plans,  medications, infection control, and transplant organ recovery. Among the specific proposals:

  • Allow one governing body to oversee multiple hospitals in a single healthcare system.
  • Allow hospitals to grant privileges to physicians and non-physicians to practice within their state's scope of practice regardless of whether they are appointed to the hospital's medical staff.
  • Revise nursing services requirements to allow hospitals to develop either a stand-alone nursing care plan or an overall interdisciplinary care plan.
  • Allow hospitals to set up a program so patients or a support person can self-administer hospital-issued medications as well as the patient's own medications brought into the hospital.
  • Eliminate the requirement that a dedicated log of infection incidents be maintained and instead allow hospitals to develop their own tracking systems.
  • Eliminate the blood typing requirement performed by transplant centers before organ recovery takes place.

The comments filed were primarily from individual physicians and nurses. The usual stakeholders also weighed in, including the American Hospital Association, American Nurses Association, and the American Medical Association. Comments were also submitted by the American Telemedicine Association, Catholic Health Initiatives, and the National Kidney Foundation.

Here's a sampling of the comments posted on regulations.org:

A 13-page letter signed by more than 80 physicians groups, including the AMA, the American Academy of Family Physicians and the American College of Surgeons, takes issue with proposed changes to the existing governance and medical staff regulations. The letter notes that CMS is not statutorily authorized to reduce the regulatory burden for hospitals or to address healthcare workforce shortages. "The statute limits CMS' authority to promulgate the CoPs in furtherance of the health and safety of hospital patients." The letter adds that the proposed changes "would be detrimental to the health and safety of patients in the hospital setting."

To allow one governing body to oversee multiple hospitals in a single healthcare system would "disenfranchise the patients of any hospital…that is unique among its member hospitals for any reason, including geographic location, services rendered and patient demographic," says the letter.

Stephen P. Blatt MD, president-elect of the Good Samaritan Hospital medical staff in Cincinnati, agrees saying, "allowing a single governing body to oversee all hospitals within a multi-hospital system would further remove the governing body from the daily operations, governance and medical staff affairs of each individual hospital. Governing bodies are essential for maintaining quality of care within hospitals and health systems and having them further removed from these issues will only worsen safety and quality of care."

No surprise that the American Hospital Association supports the governing change. "This change recognizes the more integrated organizational model adopted by many hospitals." The AHA asked CMS to clarify that hospitals with more than one CMS certification number may have a single governing body.

In its letter the AMA group also opposes allowing hospitals to grant privileges to physicians who are not on the medical staff of the hospital. The move would "allow a hospital to …exclude some physicians from the medical staff. This proposal would undermine the medical staff's chief function: self governance."

The Tennessee Medical Association notes that "the stake in quality for those of the staff and thus responsible for quality would be much different from the class beholden to the business side of hospital administration."

"The hospital medical staff is best suited and most qualified to determine provider privileges at their respective facilities," says Steve Campbell, who is identified only as being from South Carolina. "Allowing some providers to circumvent medical staff oversight will detrimentally impact patient safety and quality of care afforded to Medicare beneficiaries and all patients. In my 20 years of working in a hospital setting, I have seen cases where physicians were denied hospital staff privileges because their practices were unrelated to the mission of the hospital or their practice patterns did not meet the medical community standards. To legitimize these practices by giving them hospital status would be a disservice to the community."

The American Nurses Association would like to CMS to add language to ensure that all medical practitioners are granted clinical and medical staff privileges, including voting rights and full due process. The ANA would like advanced practice registered nurses to have admitting and discharge privileges, as well as the ability to serve on hospital committees. It supports efforts to allow hospitals to develop either a stand-alone nursing care plan or an overall interdisciplinary care plan as long as "it is recognized that nurses alone are responsible for development of the nursing care plan."

Stephanie Hutchins, an RN in California, opposes allowing the patient or a support person to administer medications in the hospital setting. She notes that studies have shown that 30% to 50% of patients ignore or otherwise compromise instructions concerning their medication. "If a person other than the nurse administers medications in the hospital, the potential for lack of adherence and therefore lack of crucial therapeutic benefit from the prescribed meds in the hospital is high. Also, if nurses are required to monitor meds given by a person other than the nurse to ensure adherence, it would create a time backlog for the nurse, negating much of the benefit of having them given by another person."

The proposal to allow hospitals to develop their own tracking systems for infection incidents is not a good idea according to the National Nurses Union, which represents 170,000 members. "There is no empirical evidence cited supporting this. The change…is being made solely on the basis of providing flexibility to the industry. Hospitals know their reimbursement, quality data, and public perceptions will be affected by infection rates, so they have a vested interest in eliminating this requirement or rendering the data meaningless …by a lack of uniformity and transparency in recording and reporting."

Catholic Health Initiatives, a Colorado-based health system with facilities in 19 states, supports allowing patients and their caregivers to administer personal and hospital-based medications. "CMS is recognizing that different hospitals have different needs and that many hospital patients are already on maintenance drugs." CHI also supports the elimination of the dedicated log of infection incidents. "Currently, CMS requires an infection and communicable disease log separate from the hospital's general infection control surveillance policy. CMS is proposing to remove this redundant and burdensome requirement."

The National Kidney Foundation agrees with the elimination of the requirement that the transplantation team verify blood type before organ recovery because organ procurement organizations already perform that function. But to prevent medical errors the foundation wants the multiple checks of blood types to be maintained before transplantation. In its letter the foundation noted recent deaths related to incompatible organ transplants.

The American Telemedicine Association wants CMS to consider the advantages of telemedicine in setting requirements for emergency care and stroke treatment. "In the last 10 years telestroke initiatives have been instituted in practically every state…it is now time for CMS to take the next step to allow hospitals the use of telemedicine to eliminate the burden and cost of maintaining their own stroke specialists."

The comment period for the proposed rules ended Dec. 23. CMS has not announced a time frame for issuing its final rule on hospital conditions of participation.

 

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Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
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